Q^^bl>\ 


\^i^ 


(£nlnmbxa  llniupraity 
I       in  tl|r  (Etty  of  '^tm  Inrk 


^£itUvnut  library 


APPLIED 


SURGICAL  ANATOMY 


REGIONALLY  PRESENTED 


FOR  THE   USE   OF   STUDENTS   AND   PRACTITIONERS 
OF  MEDICINE 


GEORGE  WOOLSEY,  A.B.,  M.  D. 

FKOFESSOR  OF  ANATOMY  AND  CLINICAL  SURGERY  IN  THE  CORNELL  UNIVERSITY  MEDICAL  COLLEGE. 

SURGEON  TO  BELLEVUE  HOSPITAL,  ASSOCIATE  SURGEON  TO  THE  PRESBYTERIAN 

HOSPITAL,    FELLOW   OF  THE   AMERICAN    SURGICAL  ASSOCIATION 

AND  OF  THE  NEW  YORK  ACADEMY  OF  MEDICINE 


With  125  Illustrations,  mostly  colored 


LEA   BROTHERS  &   CO. 

NEW   YORK  AND  PHILADELPHIA, 
1902 


GIFT 

Entered  according  to  the  Act  of  Congress  in  the  year  1902,  by 

LEA  BROTHERS  &  CO., 
In  the  OflSce  of  the  Librarian  of  Congress.    All  rights  reserved. 


PREFACE. 

Tin:  study  of  Anatomy  is  relieved  of  much  of  its  difficulty  when  it 
is  approached  on  the  practical  side.  Isolated  details  do  not  appeal  to 
the  faculty  of  interest,  but  when  they  are  set  forth  in  their  natural 
relationship,  and  tlieir  practical  application  is  pointed  out,  the  mind 
grasps  and  recollects  them  with  facility.  As  Anatomy  is  the  most 
basic  of  all  the  medical  sciences,  a  working  knowledge  of  its  data  is 
indispensable  for  the  study  and  practice  of  scientific  medicine  and  sur- 
gery. The  author  has  endeavored  to  embody  these  principles  in  the 
present  work,  and  to  do  it  in  such  a  manner  as  to  answer  the  needs  of 
both  students  and  practitioners. 

The  plan  of  the  work  has  been  developed  from  twelve  years' 
experience  in  teaching  Anatomy.  The  author  believes  the  form  of 
presentation  he  has  followed  to  be  the  best  for  didactic  lectures,  and 
that  descriptive  Anatomy  is  most  advantageously  learned  from  text- 
books and  in  the  dissecting  room.  The  regional  and  topographical 
method  of  treating  Applied  Anatomy  is  likewise  the  most  convenient 
for  clinical  purposes. 

It  is  scarcely  necessary  to  state  that  in  order  not  to  exceed  the 
proper  limits  of  a  book  designed  for  clinical  and  didactic  purposes  a 
most  careful  selection  had  to  be  made  from  the  vast  aggregate  of 
knowledge  constituting  the  modern  science  of  anatomy.  If  in  parts 
the  text  may  appear  quite  as  much  like  an  anatomical  surgery  as  a 
surgical  anatomy,  it  is  because  of  the  author's  belief  that  this  is  the 
best  way  to  complete  the  study  of  anatomy  and  to  begin  the  study  of 
surgery. 

The  author  desires  to  acknowledge  his  indebtedness  to  the  excellent 
words  of  Joessel,  Tillaux,  Merkel  and  others,  both  for  anatomical 
facts,  the  methods  of  their  presentation,  and  for  numerous  illustra- 
tions. An  original  work  on  such  a  subject  can  no  longer  be  written, 
nor  would  it  have  as  much  value  as  a  volume  duly  recognizing  the 
vast  fund  of  information  accumulated  bv  tireless  investigators.  A 
single  author  can  only  hope  to  contribute  a  fair  proportion  of  original 
knowledge  and  to  present  a  chosen  aspect  of  the  science  in  a  clear  and 
practical  manner. 

117  East  36th  St., 

New  York,  June,  1902. 

iii 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 
Columbia  University  Libraries 


http://www.archive.org/details/appliedsurgicala1902wool 


CONTENTS. 


CHAPTER   I. 


THE    HEAD   AND   NECK. 


Page. 

The  Head 17 

The  Scalp 

18 

The  Temporal  Region    .... 

24 

The  Bony  Cranium         .... 

25 

Construction  and  Lesions  of  the  Cranial 

Bones 

28 

Fractures  of  the  Skull     . 

.       30 

The  Contents  of  the  Cranium. 

.       83 

The  Cerebral  Membranes 

33 

Localization  of  Cerebral  Functions 

40 

Cranio-cerebral  Topography  . 

43 

The  Ear          .         .         .    "     . 

47 

The  Auricle  and  the  External  Auditory 

Meatus 

47 

The  Middle  Ear      .... 

52 

The  Mastoid  Antrum 

.       54 

The  Eustachian  Tube 

.       56 

The  Face 

.       59 

Region  of  the  Orbit  and  Eye. — Eyelids 

59 

The  Lachrymal  Apparatus 

63 

The  Orbit  and  its  Contents 

65 

The  Nose  and  Xasal  Fossfe     . 

72 

The  Accessory  Sinuses  of  the  Nose 

80 

The  Face 

82 

The  Parotid  Region 

88 

The  Jaws 

92 

The  Temporo-mandibular  Joint 

96 

The  Lips 

98 

The  Tongue  and  Floor  of  tlie  ^louth 

102 

The  Pahite       .          .          .          . 

107 

Tlie  Tonsils     ..... 

111 

The  Pharynx 

113 

The  Neck 

117 

The  Sterno-mastoid  Muscle     . 

118 

The  Occipital  and  Subclavian  Triangles 

120 

The  Submaxillary  Triangle     . 

132 

The  Carotid  Triangles     . 

126 

The  Hyoid  Bone      .... 

130 

The  Larynx     ..... 

132 

The  Trachea             .... 

135 

The  Thyroid  Gland 

138 

The  Deep  Cervical  Fascia 

141 

I^ymphatics  of  the  Head  and  Neck 

144 

Embryology  of  the  Neck 

145 

VI 


CONTENTS. 


CHAPTER   II. 


THE    UPPER    EXTREMITY. 


The  Region  of  the  Shoulder    . 
Anterior  Region  of  the  Shoulder 
The  Posterior  or  Scapular  Region 
The  External  or  Deltoid  Region 

The  Shoulder  Joint 
The  Axilla     . 

The  Region  of  the  Arm    . 

The  Region  of  the  Elbow 
The  Elbow  Joint     . 

The  Forearm 

The  Region  of  the  Wrist 

The  Hand  and  Fingers 


Page. 

147 
149 
155 
157 
159 
167 
170 
174 
177 
183 
187 
193 


CHAPTER   III. 


THE   THORAX. 


The  Thoracic  Walls 
The  Breast 
The  Diaphragm 
The  Contents  of  the  Thorax 

The  Pleura    . 

The  Lungs 

The  Trachea  in  the  Thorax 

The  Pericardium    . 

The  Heart      . 

The  Aorta       . 

The  Thoracic  Duct 

The  CEsophagus     . 


201 
208 
212 
214 
214 
218 
222 
223 
225 
228 
232 
233 


CHAPTER   IV 


the  abdomen. 


The  Anterior  Abdominal  Wall 

Vessels  and  Nerves  of    . 

Operations  and  Incisions 

The  Regions  of  the  Abdomen 
The  Umbilicus  and  Umbilical  Hernia     . 
The  Inguinal  Region  and  Inguinal  Hernia 
The  Inguino-Femoral  Region  and  Femoral 
The  Posterior  Abdominal  Wall 
The  Iliac  Region 
The  Lumbar  Region 
The  Abdominal  Cavity 

The  Peritoneum     . 
The  Abdominal  Viscera 
The  Stomach 
The  Small  Intestine 
The  Large  Intestine 

Ileociecal  Region 

The  Colon 
The  Liver 
The  Gall-Bladder  and  Ducts 


Hen 


236 

239 
249 
253 
255 
257 
260 
269 
274 
274 
279 
284 
284 
290 
290 
297 
306 
306 
314 
319 
325 


CONTENTS. 


VI 1 


The  Spleen    . 

The  Pancreas 

The  Kidneys 

The  Ureters 

The  Adrenals 

Vessels  of  the  Abdomen 

Nerve  Supply  of  the  Abdominal  Viscera 


Page. 

329 
332 
333 
339 
341 
342 
343 


CHAPTER   V. 

the  pelvis  and  perineum. 

The  Pelvis 

The  Lining  of  the  Pelvis 
The  Viscera  of  the  Pelvis 

The  Eectum 

The  Bladder 

The  Prostate 

The  Seminal  Vesicles     . 

The  Vas  Deferens 
The  Female  Pelvic  Genital  Organs 

The  rterus     . 

The  Ovary      . 

The  Fallopian  Tubes      . 

The  Broad  Ligaments    . 

The  Eound  Ligaments  . 

The  Vagina    . 

The  Female  Urethra 
External  Genitals 

The  Female  External  Genitals 

The  Male  Urethra 

The  Penis 

The  Scrotum 

The  Testis      . 
The  Perineum    . 

The  Ischio-rectal  Region 

CHAPTER  VI. 


345 
354 
358 
358 
365 
373 
376 
378 
379 
379 
385 
388 
389 
391 
392 
395 
397 
397 
398 
405 
409 
412 
417 
424 


the  lower  extremity 


The  Hip 

The  Gluteal  Region  or  Buttocks 

The  Region  of  Scarpa's  Triangle 

The  Hip  Joint 
The  Thigh 
The  Region  of  the  Knee 

The  Knee  Joint 
The  Leg      .... 
The  Ankle 

The  Ankle  Joint    . 
The  Foot    .... 


426 
426 
430 
434 
445 
449 
453 
460 
465 
468 
472 


The  Spine 

The  Spinal  Cord     . 


CHAPTER    VTT. 

THE    SPINK. 


484 
491 


APPLIED   SURGICAL   ANATOMY. 


CHAPTER    I. 

THE   HEAD  AND   NECK. 

THE    HEAD. 

General  Considerations. — The  head  is  auatomically  the  most  essen- 
tial and  most  complex  part  of  the  body.  It  is  of  great  practical 
interest,  for  even  its  smaller  parts  are  of  importance  to  the  life  and 
well-being  of  man.  In  individuals  of  medium  height  and  weight  the 
head  measures  g  of  the  body  height  in  men  and  ^^  in  women,  and 
ireifjhs  Jy  of  the  body  weight  in  men  (4  k.g.)  and  -^^  in  women  (3.G 
k.g.).  The  larger  the  individual  so  much  smaller  is  the  head  as  com- 
pared with  the  total  height  and  weight. 

When  the  face  looks  directly  forward  the  external  auditory  meatus 
and  infraorbital  margin  are  in  a  horizontal  plane.  Such  a  position, 
the  one  most  naturally  assumed,  is  maintained  by  the  posterior  neck 
muscles  and  not  by  gravity,  for  the  line  of  the  latter  lies  in  front  of 
the  transverse  occipito-atlantoid  axis  of  motion. 

As  compared  with  the  human  skull  that  of  the  hir/her  apf'.s  (chim- 
panzee, orang,  etc.)  shows  marked  differences,  /.  e.,  the  projection  of 
the  muzzle,  the  greater  size  and  forward  position  of  the  face,  the 
greater  size  of  the  intermaxillary  bones,  the  backward  and  oblique  ])o- 
sition  of  the  foramen  magnum,  etc.  Idiots''  skulls  approximate  those  of 
the  lower  animals  in  many  respects,  i.  e.,  large  face,  small  cranium,  etc. 

The  head  shows  a  tendency  to  asj/mmetri/.  One  error  often  com- 
pensates for  another  and  one  is  often  astonished  in  the  examination 
of  the  separate  parts  to  find  considerable  deformity  whose  existence 
escapes  a  general  observation.  Indivitlual  ditferences  in  the  head  are 
marked,  as  they  are  elsewhere  in  the  body,  but  we  are  accustomed  to  ob- 
serve them  more  closely  as  they  are  the  essential  marks  of  individuality. 

But  besides  the  individual  differences  there  are  those  of  sex,  age 
and  race.  Thus  the  female  skull  looks  immature,  resembling  that  of 
a  child,  and  is  smaller,  lighter,  broader  and  less  high,  the  face  and 
lower  jaw  are  smaller  and  the  vertex  is  flattened.  The  circumference 
of  the  skull  at  birth  is  greater  than  that  of  any  other  part  of  the 
body.  The  skull  at  birth  is  characterized  by  the  large  size  of  the 
cranium  and   the  small   size  of  the  face  and  the  base;  the  absence  of 

2  17 


18  THE  HEAD  AND  NECK. 

the  mastoid  process,  the  diploe  and  all  ridges ;  the  presence  of  the 
anterior  fontanelle  and  the  prominence  of  the  frontal  and  parietal 
eminences.  It  resembles  more  closely  the  skull  of  the  lower  animals 
than  does  the  adult  skull. 

During  the  fird  seven  years  the  skull  grows  very  rapidly,  at  first 
more  or  less  equally.  During  the  first  dentition  the  fontanelles  close, 
the  face  broadens  and  enlarges,  the  jaws  lengthen  and  the  zygomatic 
arches  project.  Later  the  base  of  the  skull  lengthens  and  the  face 
becomes  deeper  and  somewhat  longer.  By  the  seventh  year  some  parts 
have  attained  their  growth,  /.  e.,  the  foramen  magnum,  the  petrous 
portion  of  the  temporal  bone,  the  width  of  the  body  of  the  sphenoid 
and  of  the  cribriform  plate.  Near  the  approach  of  puberty  a  second 
period  of  active  growth  begins,  the  face  is  elongated  from  the  increased 
height  of  the  nasal  fossae,  alveolar  arches  and  second  teeth  and  the 
expansion  of  the  air  sinuses.  In  lutev  years  the  latter  continue  to 
expand,  up  to  old  age,  the  crests  and  ridges  develop  and  the  frontal 
region  elongates.  In  old  age  the  skull  atrophies,  becoming  thinner, 
lighter  and  perhaps  smaller  by  absorption  on  the  surface  and  redeposit 
on  the  interior.  The  face  becomes  smaller  by  the  loss  of  the  teeth 
and  the  absorption  of  the  alveolar  processes. 

The  racial  differences  although  marked  in  typical  examples  shade 
into  each  other.  According  to  one  classification  we  may  distinguish  : 
(Ij  the  prognathous  or  long-headed  type,  with  projecting  jaws  and 
teeth,  as  in  the  negro,  (2)  the  pyramidal  or  broad,  flat-faced  type,  with 
narrow  forehead,  as  in  the  Mongolian  or  Esquimaux  and  (3)  the  oval 
type  of  the  European,  with  the  length  of  (1),  or  even  more,  and  the 
breadth  of  (2),  but  the  teeth  do  not  project  as  in  (1)  nor  the  zygomatic 
arches  as  in  (2),  and  the  forehead  is  full,  laterally,  and  high.  Again 
skulls  are  classified  as  I.  Dolicocephallc,  or  "long-headed,"  in  which 
the  occipital  lobes  overlap  the  cerebellum  and  II.  Brachycephalic,  or 
"  short-headed,"  in  which  the  occipital  lobes  do  not  extend  so  far 
backward.  Each  division  is  subdivided  into  ortJiognat/wus  in  which 
the  jaws  and  teeth  do  not  project  and  prognathous  in  which 
they  do. 

Other  peculiar  forms  of  skull  are  on  the  border  line  of  pathological 
deformities,  depending  upon  the  premature  closure  of  a  certain  suture 
whicli  prevents  the  growth  of  the  skull  at  right  angles  to  that  suture 
and  forces  it  to  grow  in  other  directions,  if  at  all.  By  the  same 
process,  extended  to  several  sutures,  raicrocephalus  may  result.  The 
latter  may  be  the  result  or  cause  of  idiocy,  in  the  latter  case  justifying 
operation  (craniectomy). 

THE  SCALP. 

The  soft  parts  covering  the  vault  of  the  skull  are  arranged  as  in 
no  other  part  of  the  body.  There  are  five  layers  :  (1)  The  skin,  (2) 
the  subcutaneous  fatty  tissue,  (3)  the  occipito-frontalis  muscles  and 
aponeurosis,  (4)  the  subaponeurotic  areolar  tissue,  and  (5)  the  peri- 
cranium.     The  first  three  layers  are  so  intimately  blended   Avith  one 


TJIK   SUBCUTAl^EOVS  TISSUE. 


19 


another,  especially  over  the  aponeurotic  portion  of  the  occipito-frontalis, 
that  they  form  virtually  a  single  layer,  the  scalp  (see  Fig.  1). 


SUBCUTANEOUS 
TISSUE 

APONEUROSIS 
SUBAPONEUROTIC    TISSUE 
PERICRANIUM 

-SAGITTAL    SUTURE 

—  PARIETAL    BONE 

-^TWO    LAYERS    OF    DURA 

—  LONGITUDINAL    SINUS 


FALX   CEREBRI 


Frontal  section  of  scalj)  and  skull  through  the  sagittal  suture  and  the  superior  longitudinal  sinus. 

1.  The  skin  of  the  scalp  is  thicker  than  that  in  most  regions  of 
the  body  and  is  thicker  behind  than  in  front.  The  liair  is  so  strongly 
attached  to  the  scalp  that  it  has  supported  the  weight  of  the  body  in 
many  instances  since  the  days  of  Absalom,  as  for  example  where  it  is 
caught  in  revolving  machinery  belts  and  the  body  is  drawn  after  it. 
The  entire  scalp  has  also  been  torn  oif  in  such  accidents.  The  hair 
should  always  be  shaved  around  scalp  wounds,  otherwise  it  is  impossible 
to  make  and  keep  them  clean.  Although  the  roots  of  the  hairs  may 
extend  deeply  into  the  subcutaneous  fatty  tissue  the  numerous  seba- 
ceous glands  associated  with  them  are  superficial  in  the  skin.  These 
may  develop  into  sebaceous  tumors  or  wens  which  are  more  common 
here  than  in  any  other  part  of  the  body.  Owing  to  their  superficial 
position,  external  to  the  aponeurosis,  they  are  easily  and  safely  removed. 
Care  must  be  taken  however  in  removing  suppurating  sebaceous  cysts 
not  to  divide  the  aponeurotic  layer  on  account  of  the  danger  of  infec- 
tion of  the  loose  tissue  i)en('ath. 

2.  The  subcutaneous  tissue,  5-0  mm.  in  thickness,  is  composed 
of  a  great  number  of  strong  fibrous  bands  closely  binding  together  the 
skin  and  aponeurosis  and  forming  a  multitude  of  small  compartments 
enclosing  lobules  of  fat.  On  account  of  this  disposition  of  the  fat  it 
follows  that  fatty  tumors  are  rare  and  that  there  is  but  little  increase 
of  it  in  obesity,  though  a  perceptible  decrease  exists  after  long  sickness. 
The  falling  out  of  the  hair  in  such  cases  may  be  partly  due  to  this  fact. 

The  arrangement  of  this  subcutaneous  tissue,  like  that  in  the  palm, 
admirably  adapts  it  to  resist  jiressure.  It  makes  the  densitv  of  the 
scalp  such   that   in   surface  inflammations,  as  in   erysipelas,  the  scalp 


20  THE  HEAD  AXD  NECK. 

swells  but  slightly,  is  but  little  reddened  and  is  extremely  painful.  It 
attaches  the  skin  so  closely  to  the  aponeurosis  and  muscle  that  the 
former  moves  with  all  the  movements  of  the  latter.  Furthermore 
this  layer  contains  the  vessels  which  supply  the  three  layers  of  the 
scalp.  These  vessels  are  closely  connected  with  the  fibrous  partitions 
of  this  layer  so  that  in  wounds  of  the  scalp  the  vessels  which  are 
divided  are  unable  to  retract  or  contract,  hence  hemorrhage  is  free  and 
is  not  spontaneously  arrested.  Tumors  situated  external  to  the  aponeu- 
rosis move  with  the  scalp  ;  immovable  growths  are  probably  beneath 
the  aponeurosis. 

3.  The  aponeurosis  occupies  the  space  between  the  two  muscular 
portions  of  the  occipito-frontalis,  in  front  and  behind.  It  extends 
down  laterally  over  the  temporal  fascia  as  a  cellular  layer,  and  over 
the  zygomatic  arch  without  attachment  to  it. 

4.  The  subaponeurotic  areolar  layer  is  a  layer  of  loose  connective 
tissue  whose  looseness  serves,  like  a  serous  membrane,  to  facilitate  the 
movement  of  the  scalp  upon  the  pericranium,  a  condition  which  is 
more  marked  in  the  young  than  in  the  old.  This  looseness  of  attach- 
ment allows  the  gaping  of  scalp  wounds  and  the  ready  separation  of 
large  flaps  of  scalp  by  injuries,  operations,  scalping  by  Indians  or  in 
autopsies.  It  is  known  as  the  dangerous  area  of  the  scalp,  for  its 
loose  structure  allows  the  wide  and  rapid  spread  of  inflammation  and 
pus,  posteriorly  as  far  as  the  superior  curved  line,  anteriorly  to  the 
superciliary  ridges,  and  laterally  to  or  even  below  the  level  of  the 
zygoma.  Wounds  or  incisions  which  extend  through  the  entire  scalp 
and  open  into  this  layer  are  much  more  serious  than  more  superficial 
ones  on  account  of  the  more  serious  consequences  of  infection.  This 
layer  contains  but  few  blood  vessels  which  cross  it  to  enter  the  peri- 
cranium, otherwise  large  eff*usions  of  blood  would  be  far  more  common 
here  than  they  are. 

5.  The  pericranium  is  remarkable  for  its  slight  adherence  to  the 
bone  except  along  the  sutures,  where  it  is  attached  to  the  suture  mem- 
brane and  is  thus  continuous  with  the  dura,  as  it  is  also  at  the  foramina. 
Hence  inflammation  of  the  pericranium  may  extend  by  continuity  to 
the  dura  at  the  foramina  and  sutures  where  the  two  become  continuous. 
It  follows  also  that  the  ])ericranium  may  be  widely  stripped  up  from 
the  underlying  bone  in  extensive  scalp  wounds.  Such  an  injury  is  of 
less  importance  than  we  would  expect  from  analogy  with  similar 
injuries  of  the  periosteum  elsewhere.  The  skull  bones  seldom  necrose 
under  such  circumstances,  for  they  derive  their  main  blood  supply 
from  the  vessels  of  the  diploe  and  dura.  For  a  similar  reason  loss  of 
bone  in  the  vault  of  the  adult  skull  due  to  injury,  necrosis  or  opera- 
tion, is  as  a  rule  not  repaired,  for  neither  the  pericranium  nor  the  dura 
reproduce  bone  as  does  the  periosteum. 

Vessels  of  the  Scalp. — The  vascularity  of  the  scalp  is  greater  than 
that  of  any  other  part  of  the  surface.  Flaps  of  scalp,  however  large 
and  extensively  stripped  up,  almost  always  live,  for  the  scalp  carries 
its  own  blood  supply,  which  enters  at  the  pedicle  of  the  flap.     Slough- 


Tllh:  EMISSARY  VEINS.  21 

ing  and  gangrene  from  pressure  are  rare  owing  to  the  density  of  the 
scalp  tissue  in  which  the  vessels  run.  Unlike  other  regions  of  the 
body,  where  vessels  of  any  size  are  subfascial,  the  vessels  of  the  scalp 
lie  in  the  subcutaneous  tissue  alone. 

The  arteries  come  from  the  occipital,  posterior  auricular  and  super- 
ficial temporal  branches  of  the  external  carotid  and  from  the  supra- 
orbital and  frontal  branches  of  the  ophthalmic.  Each  vessel  converges 
upward  toward  the  vertex  of  the  skull  and  anastomoses  freely  with 
the  adjoining  ones  and  with  its  fellow  of  the  opposite  side.  It  follows 
that  incisions  should  be  planned  as  far  as  possible  to  radiate  from  the 
vertex,  or,  if  horseshoe-shaped,  to  have  the  base  below  and  the  free 
end  toward  the  vertex.  To  prevent  hemorrliage  during  an  operation 
rubber  tubing  may  be  tightly  drawn  around  the  base  of  the  scalp,  or 
to  diminish  it  overlapping,  interrupted,  temporary  sutures  may  be 
applied  between  the  incision  or  flap  and  the  base  of  the  scalp,  from 
whence  the  arteries  pass  upward.  The  frontal  urtery  emerging  at  the 
inner  angle  of  the  orbit  on  each  side,  enters  at  the  base  of  and  supplies 
the  flap  that  is  taken  from  the  forehead  to  form  a  new  nose  in  rhino- 
plasty. The  temporal  artery  with  the  aiiriculo-temporal  nerve  behind 
it  ascends  between  the  condyle  of  the  jaw  and  the  external  auditory 
meatus  over  the  posterior  root  of  the  zygoma  and  divides  into  its 
anterior  and  posterior  branches  1|  to  2  inches  above  the  latter.  It 
presents  in  a  high  degree  the  tortuosities  of  the  arteries  of  the  head, 
especially  its  anterior  branch,  and,  in  the  aged,  it  affords  early  evidence 
of  arterial  sclerosis.  It  is  the  most  frequent  situation  for  cirsoid 
aneurism  and  is  more  frequently  wounded  than  almost  any  other 
artery  of  the  body.  The  posterior  auricular  artery  and  nerve  run  in 
the  angle  between  the  ear  and  the  mastoid  process.  The  occipital 
artery  ascends  a  finger's  breadth  behind  the  mastoid  process  and 
reaches  the  scalp,  with  the  great  occipital  nerve  a  little  internal  to  a 
point  midway  between  the  mastoid  process  and  the  occipital  protuber- 
ance. These  arteries  all  share  the  peculiarity  of  being  subcutaneous 
instead  of  being  subaponeurotic. 

The  emissary  veins  connect  the  dural  sinuses  with  the  superficial 
veins  at  certain  points  through  apertures  in  the  skull  and  hence  are 
of  considerable  practical  importance.  They  afford  a  channel  for  the 
spread  of  inflammation  from  the  surface,  to  the  sinuses  or  meninges, 
thereby  causing  sinus  thrombosis  or  meningitis,  as  in  cases  of  ery- 
sipelas and  su|)purati<>n  of  the  scalp  or  necrosis  of  the  cranial  bones. 
Their  presence  adds  greatly  to  the  seriousness  of  injuries  and  diseases 
of  the  scalp.  They  also  assist  in  equalizing  the  intracranial  pressure 
and  for  this  puri)ose  are  most  developed  in  early  life,  during  the  period 
of  i)rain  growth. 

The  most  constant  and  important  of  the  emissary  veins  connecting 
with  the  veins  of  the  scalp  are:  (1)  the  vein  passing  through  the 
mastoid  foramen  which  connects  the  lateral  sinus  with  the  occipital  (or 
posterior  auricular)  vein  ;  (2)  the  vein  passing  through  the  posterior 
condylar   foramen   which  connects  the  sigmoid  sinus   with    the  deep 


22  THE  HEAD  AXD  XECK. 

veins  at  the  back  of  the  neck ;  (3)  the  vein  passing  through  the 
parietal  foramen  which  connects  the  superior  longitudinal  sinus  with 
the  veins  of  the  scalp.  The  inastoid  emissary  vein  accounts  for  the 
practice  of  blood  letting  or  blistering  behind  the  ear  in  some  cerebral 
affections  and  for  the  oedema  behind  the  mastoid  process  in  lateral 
sinus  thrombosis.  For  the  other  emissary  veins  see  any  descriptive 
anatomy. 

The  veins  of  the  scalp  are  also  connected  by  many  minute  veins 
with  the  veins  of  the  diploe.  The  latter  are  not  well  developed  until 
after  the  tenth  year  when  the  diploe  develops  and  they  are  separate 
for  each  bone  until  the  ossification  of  the  sutures  (Testut).  The  veins 
of  the  diploe  communicate,  the  anterior  two  (frontal  and  anterior 
temporal)  with  the  surface  veins  (su])raorl)ital  and  deep  temporal),  the 
posterior  two  (posterior  temporal  and  occipital)  with  the  lateral  sinus. 
The  anastomosis  between  the  angular  and  su})raorbital  veins  at  the 
inner  angle  of  the  orbit  affords  a  free  communication  between  the  extra- 
and  intracranial  circulation,  as  the  supraorbital  vein  through  the  oph- 
thalmic is  a  tributary  of  the  cavernous  sinus.  Thus  we  see  the  number 
of  channels,  and  there  are  other  less  conspicuous  ones,  through  which 
inflammation  can  spread  from  the  surface  to  the  interior  of  the  skull. 

The  lymphatics  of  the  scalp  may  be  divided  into  three  groups:  (1) 
The  occipital  emptying  into  the  suboccipital  nodes  ;  (2)  the  posterior 
parietal  emptying  into  the  mastoid  nodes,  and  (3)  the  anterior  parietal 
and  frontal  which  empty  into  the  parotid  nodes.  Some  vessels  from 
the  frontal  region  end  in  the  submaxillary  nodes.  A  knowledge  of 
these  regions  and  their  nodes  is  of  service  in  the  diagnosis  of  scalp 
troubles  in  which  they  are  affected. 

With  regard  to  the  nerves  which  sujiply  the  scalp  it  is  only  neces- 
sary to  say  that  those  which  are  branches  of  the  fifth  nerve  are  not 
infrecjuently  the  seat  of  neuralgia,  especially  the  supraorbital  nerve,  less 
often  the  auriculo-temporal.  The  former  emerges  from  the  orbit  at  the 
supraorbital  foramen  or  notch,  at  the  junction  of  the  inner  and  middle 
thirds  of  tlie  supraorbital  margin.  Here  it  maybe  readily  found  and 
divided  or  resected  in  some  forms  of  obstinate  frontal  headache  due  to 
neuralgia  of  this  nerve.  The  inner  branch  reaches  back  to  the  middle 
of  the  parietal   bone,  the  outer  branch  as  far  as  the  lambdoid  suture. 

Wounds  of  the  scalp  do  not  gape  unless  the  aponeurosis  or  muscle 
is  divided.  Those  wounds  gape  most  which  are  transverse  to  the 
muscle  fibers,  next  those  transverse  to  the  aj)oneurotic  fibers,  and  those 
gape  least  which  are  parallel  with  them,  /.  e.,  antero-posterior.  As 
the  seal])  is  firmly  stretched  over  the  hard  bone  beneath,  contused 
wounds  often  appear  as  cleanly  cut  as  incised  wounds.  Wounds  resem- 
bling incised  wounds  may  also  be  produced  from  within  by  the  sharp 
edge  of  the  superciliary  ridge  when  struck  by  a  blunt  object. 

Bleeding  from  scalp  wounds  is  very  free  and  unless  j)roperly  treated 
very  prolonged.  There  is  little  or  no  tendency  to  the  spontaneous 
arrest  of  hemorrhage,  for  the  arteries,  owing  to  their  adhesion  to  the 
tissues  of  the  scalp,  are  unable  to  retract  or  contract  when  divided, 


HJEMATOMATA.  23 

and  it  is  by  this  process  that  hleedino;  is  ordinarily  sj)ontaneously 
arrested.  This  adhesion  and  the  density  of  the  scalp  account  for  the 
difficulty  of  tyintr  a  blcedintj;  artery  in  the  scalp,  iience  to  arrest  heni- 
orrhuf^e  we  often  de])end  upon  pressure,  a  suture  passed  beneath  the 
vessel  or  upon  suturing  the  edges  of  the  wf)un(l  firmly  togetiier.  For- 
tunately, as  we  have  seen  above,  there  is  very  little  (langer  of  slough- 
ing on  account  of  pressure.  In  addition  to  the  arrest  of  bleeding  we 
have  ((I  think  of  the  ])ossil)ilities  of  inflammation  in  scalp  wounds. 

Inflammation  or  abscess  in  the  scalp  nuw  occur  in  one  of  three 
situations,  (1)  in  the  subcutaneous  tissue,  (2)  between  the  aponeurosis 
and  the  pericranium,  and  (3)  beneath  the  pericranium.  Abscesses  of 
the  first  variety  are  small  and  spread  only  with  the  greatest  difficulty 
in  the  dense  tissue.  In  the  second  situation  inflammation  or  abscess 
may  be  very  serious  on  account  of  its  easy  spread  in  the  loose  tissue 
and  the  danger  of  the  infection  extending  within  the  cranium.  In- 
flammations of  this  kind  may  follow  scalp  wounds  involving  the  apo- 
neurosis and  the  chief  danger  of  these  wounds  lies  in  such  inflamma- 
tions. The  inflammation  may  undermine  the  entire  scalp  and  is  limited 
only  by  the  attachments  of  the  aponeurosis  as  given  above.  The  scalp 
does  not  perish  even  in  the  most  extensive  cases,  as  it  carries  its  own 
blood  supply,  but  the  wounds  which  lead  to  the  abscess  or  are  made 
to  relieve  it  are  often  slow  to  heal,  as  the  abscess  walls  fail  to  obtain 
perfect  rest  owing  to  the  movements  of  the  occipito-frontalis  muscle. 
Abscess  beneath  the  pericranium  is  limited  to  the  surface  of  one  bone 
as  this  membrane  is  adherent  to  the  suture  membrane.  It  is  most 
often  the  result  of  necrosis  of  the  cranial  bones. 

Haematomata  of  the  scalp  may  be  classified  in  the  same  manner  as 
abscess.  They  occur  most  frequently  outside  of  the  aponeurosis  in  the 
subcutaneous  tissue  which  contains  the  greater  part  of  the  blood  ves- 
sels. In  this  situation  the  extravasation  of  blood  is  usually  small  and 
sharply  limited  by  the  density  of  the  tissues  and  is  confined  to  the  area 
where  the  tissues  are  lacerated  by  violence.  Such  extravasations  of 
blood  produce  a  tumor  on  the  surface  whose  thin  edges  become  hard 
from  the  coagulation  of  the  thin  layer  of  blood  while  the  thicker  center 
remains  soft  for  a  time.  A  firm  sharp  margin  often  separates  these 
two  parts  which  may  lead  to  a  mistake  in  diagnosis  by  mistaking  it 
for  the  margin  of  a  fracture  of  the  skull  and  the  soft  center  for  the 
depression  of  an  area  of  the  skull.  This  error  may  be  avoided  by 
observing  the  projection  of  the  blood  tumor  on  the  surface  and  bv 
moving  the  scalp  back  and  forth,  when  the  supposed  depressed  area 
moves  with  the  scalp  over  the  surface  of  the  skull.  Owing  to  its 
poverty  in  blood  vessels  the  loose  tissue  beneath  the  aponeurosis  is  not 
often  the  seat  of  a  hematoma  except  as  the  result  of  fracture  of  the 
skull.  When  they  occur  here  they  may  attain  a  large  size  and  may 
similarly  present  hard  edges  and  a  soft  center,  sinuilating  depressed 
fracture,  from  which  they  cannot  be  distinguished  by  moving  the  scalp. 

Extravasations  of  blood  beneath  the  pericranium  are  limited  in  area 
to  one  bone  and  may  be  diagnosed  by  this  fact.     Tlu'v  are  commonly 


24  THE  HEAD  AND  NECK. 

called  cephalhematomata,  are  usually  congenital  in  origin,  due  to  pres- 
sure on  the  head  at  birth,  and  hence  are  more  frequent  in  males  owing 
to  the  larger  size  of  the  head.  They  are  most  common  over  the 
parietal  bone  and  on  the  right  side,  which  is  most  exposed  to  pressure. 
Besides  these  blood  tumors  beneath  the  pericranium  others  occur 
rarely  which  have  a  different  origin  and  are  distinguished  by  disap- 
pearing on  pressure,  in  whole  or  in  part,  or  even  in  the  upright  pos- 
ture. Such  tumors  according  to  their  position  are  connected  either 
with  the  veins  of  the  diploe  or  the  dural  sinuses  through  an  opening 
which  may  be  the  result  of  injury,  disease  or  congenital  defect.  When 
communicating  with  the  superior  longitudinal  sinus  they  are  median 
and  receive  a  faint  pulsation  from  the  brain. 

THE    TEMPORAL   REGION. 

The  temporal  region  varies  in  some  respects  from  the  scalp  proper 
as  to  the  soft  parts  covering  it.  The  limits  of  this  region  may  be 
taken  to  be  the  upper  border  of  the  zygomatic  arch,  the  external  audi- 
tory meatus  and  the  base  of  the  mastoid  process  below  and  the  curved 
superior  temporal  ridge  above.  The  latter  ridge  connects  the  base  of 
the  mastoid  bone  with  the  external  angular  process  of  the  frontal  bone 
and  rises  7  to  8  cm.  above  the  level  of  the  zygomatic  arch.  This 
region  corresponds  to  the  temporal  fossa  and  its  upper  limits  may  be 
determined  by  making  the  temporal  muscle  to  contract.  The  various 
layers  of  soft  parts  common  to  this  region  and  the  occipito-frontal  are 
identical  above,  where  they  really  form  a  part  of  the  scalp,  but  change 
in  character  below.  Thus  the  skiu,  below,  is  less  dense,  less  thick 
and  less  adherent  to  the  subcutaneous  tissue  and  is  wanting  in  hair 
below  and  in  front.  The  subcutaneous  tissue,  below,  becomes  loose 
and  resembles  that  elsewhere  in  the  body  and  the  arteries  are  no  longer 
intimately  adherent  to  its  septa.  The  aponeurosis  passes  down  over 
the  zygoma  onto  the  cheek,  becoming  loose,  thin  and  lamellar.  Tiie 
loose  subaponeurotic  tissue  is  like  that  above,  but  loosely  connects  the 
aponeurosis  with  the  temporal  fascia  instead  of  with  the  pericranium. 

Tlie  temporal  fascia,  whose  form  represents  exactly  that  of  this 
region,  is  very  dense  and  unyielding,  so  that  in  the  case  of  an  injury 
reported  by  Denonvilliers  a  lacerated  wound  of  this  fascia  was  at  first 
mistaken  for  a  fracture  of  the  skull.  In  its  lower  third  it  is  double, 
enclosing  fat  and  the  orbital  branch  of  the  temporal  artery  between 
its  two  layers,  which  are  attached  to  the  outer  and  inner  aspects  of  tlie 
upper  border  of  the  zygomatic  arch.  Between  it  and  the  bone  is  an 
osseo-apoueurotic  space  which  is  deepest  in  front  (2  J  cm.)  and  narrows 
behind  and  above  until  we  reach  the  attachment  of  the  fascia  to  the 
bone.  This  space  lodges  the  temporal  muscle  and  deep  temporal  ves- 
sels and  nerves.  It  is  hermetically  closed  above  by  the  attaclnnent  of 
the  fascia  to  the  temporal  ridge,  while  below  it  is  directly  contiuuous 
with  the  zygomatic  fossa,  so  that  surgically  the  two  fossae  form  but  a 
single  region.     Hence  abscess,  etc.,  in  the  temporal  fossa  is  prevented 


SURFACE   LANDMARKS.  25 

by  the  firm  fascia  from  opening  above  the  zygoma  and  tends  to  extend 
downward  into  the  zygomatic  fossa  and  the  neck.  Owing  to  the 
density  of  the  fascia  pathological  collections  beneath  it  do  not  show 
on  the  surface. 

As  in  the  scalj),  inflammatory  ])rodiicts  or  blood  may  collect  in  the 
subcutaneous  or  subaponeurotic  layers,  in  which  situations  they  may 
be  wholly  above  the  zygoma  or  sink  in  part  below  its  level.  Subcu- 
taneous effusions  lie  external  to  the  zygomatic  arch  while  those  beneath 
the  fascia  are  internal  to  the  arch.  In  the  temporal  region  the  peri- 
cranium is  much  thinner  and  more  adherent  to  the  bone  while  the  dura 
is  less  so  than  it  is  above,  hence  subpericranial  extravasations  are  rare 
while  epidural  extravasations  are  more  common  than  elsewhere. 

As  the  muscle  is  sei)arated  from  the  fascia  in  the  lower  third  of  this 
region  by  a  mass  of  fat,  continuous  with  the  abundant  masses  in  the 
zygomatic  fossa,  we  see  that  there  are  three  distinct  layers  of  fat 
between  the  surface  and  tiie  muscle  :  (1)  Subcutaneous,  (2)  inter- 
fasciai,  (3)  subfascial.  This  fat  diminishes  in  wasting  diseases,  giving 
a  sunken  appearance  to  the  temporal  region,  and  bringing  the  zygo- 
matic arcli  and  the  malar  bone,  below  and  in  front,  into  prominent  relief. 

The  mastoid  region,  corresponding  to  the  triangular  mastoid  proc- 
ess, is  covered  by  the  same  layers  as  the  occipito-frontal  but  the  skin, 
subcutaneous,  aponeurotic  and  subaponeurotic  tissues  are  altered  as  in 
the  lower  temporal  regions  so  as  to  resemble  the  similar  layers  else- 
where in  the  body.  The  pericranium  is  very  thick  and  adherent  and 
is  more  like  periosteum  elsewhere. 

THE    BONY    CRANIUM. 

Surface  Landmarks. — Those  that  can  be  determined  through  the 
overlying  scalp  are  of  the  most  surgical  importance  in  relation  to 
cranio-cerebral  topography.  The  external  occipital  protuberance,  or 
inion,  is  readily  felt  in  the  median  line.  It  is  the  thickest  part  of  the 
vault  and  corresponds  about  to  the  torcular  Herophili  on  the  inner  sur- 
face. The  glabella,  the  median  smooth  area  between  the  superciliary 
ridges  of  the  frontal  bone,  can  be  felt  just  above  the  notch  [lumon)  at  the 
naso-frontal  suture.  The  external  angular  process  of  the  frontal  bone 
at  the  outer  end  of  the  supraorbital  ridge  is  readily  felt.  Measure- 
ments are  taken  from  its  upper  and  outer  part.  It  should  not  be  con- 
founded with  a  projection  on  the  back  of  the  frontal  process  of  the 
malar  bone  below  it.  The  zi/f/onuitic  arch,  the  cvtcniaf  (tudiforif  meatus 
and  the  mastoid  proceas  can  all  be  readily  seen  or  felt.  The  upper 
branch  of  the  })osterior  root  of  the  zygoma  {supramaHfoid  crest)  running 
into  the  posterior  part  of  the  temporal  ridge  can  be  felt  above  and 
behind  the  external  auditory  meatus.  The  parietal  eminence  is  used 
as  a  landmark  but  is  not  a  well  marked  one.  To  determine  it  the 
scalp  should  be  shaved,  and  it  c^m  be  more  accurately  determined 
when  the  skull  is  bared.      It  is  more  ]irominent  in  young  skulls. 

In  addition  to  these  pali)able  or  visible  landmarks  and  by  means  of 


26  THE  HEAD  AND   XECK. 

them  we  can  determine  the  position  of  the  sutures.  The  bregma,  the 
site  of  the  anterior  fontanelle  where  the  sagittal  and  coronal  sutures 
meet,  lies  at  the  intersection  of  the  median  line  with  a  vertical  line 
drawn  from  ajwint  just  in  front  of  the  external  auditory  meatus.  The 
coronal  suture  lies  in  a  line  from  the  bregma  to  the  middle  of  the  zygo- 
matic arch.  The  pterion  Avhere  the  frontal  parietal  and  great  wing  of 
the  sphenoid  meet,  lies  on  this  line  about  1|  inches  behind  the  exter- 
nal angular  process  of  the  frontal  and  about  the  same  distance  above 
the  zygoma.  The  sar/itfal  suture  is  median  and  extends  between  the 
bregma  and  the  lambda.  The  latter  corresponds  to  the  posterior  fon- 
tanelle and  is  about  midway  between  the  bregma  and  inion  (external 
occipital  protuberance),  or  2|  inches  above  the  latter.  The  parietal 
foramen  is  about  4  cm.  above  the  lambda.  The  lanibdoid  suture  }oms 
the  sagittal  at  the  lambda  and  extends  thence  along  a  line  drawn  to 
the  posterior  end  of  the  base  of  the  mastoid  process,  or  it  may  be  rep- 
resented by  the  ])osterior  two-thirds  of  a  line  from  the  lambda  to  the 
apex  of  the  mastoid.  The  aster  ion,  at  the  postero-inferior  angle  of  the 
parietal  bone  where  the  lambdoid  and  parieto-mastoid  sutures  meet, 
lies  on  the  last-mentioned  line  1|  inches  behind  the  meatus  and  on  a 
level  with  the  zygoma.  The  summit  of  the  squamous  suture  is  about 
2  inches  above  the  zygomatic  arch.  It  should  be  remembered  that 
tlie  frontal  suture,  between  tlie  two  halves  of  the  frontal  bone,  some- 
times persists,  and  should  not  be  mistaken  for  a  fracture. 

The  sutures,  besides  interlocking  in  a  serrated  or  dentated  manner, 
are  bevelled  alternately  at  the  expense  of  the  outer  and  inner  aspect. 
Thus  in  the  coronal  suture  the  frontal  overlaps  the  parietal  above  and 
is  overlapped  by  it  below.  In  injuries  to  the  skull  diastccsis  or  separa- 
tion of  the  bones  at  the  sutures  occurs  in  but  a  very  small  percentage 
of  cases  and  then  usually  in  connection  with  an  extensive  fracture.  It 
is  naturally  more  common  in  young  than  in  adult  skulls.  The  squa- 
mous suture  is  the  one  where  diastasis  is  most  common,  or  when  asso- 
ciated with  fracture,  the  sagittal  and  coronal  sutures.  The  suture 
membrane  in  young  skulls  is  thick  and  vascular  so  that  a  surface  in- 
flammation may  travel  through  it  to  the  internal  surface  of  the  cranium 
and  vice  versa.  In  hi/drocephalus  the  sutures,  especially  those  around 
the  parietal  bone,  become  \videly  separated  and  the  fontanelles  form 
large  openings  whose  closure  is  much  delayed.  The  posterior  fonta- 
nelle is  normally  closed  at  birth  and  the  anterior  during  the  second 
year,  up  to  which  time  it  acts  as  a  safety  valve  for  the  rapidly  varying 
intracranial  pressure.     It  may  persist  much  longer,  even  to  adult  life. 

As  the  sutures  with  their  membranes  allow  the  rapid  growth  of  the 
skull  their  premature  closure  prevents  the  growth  of  bone  in  a  line 
at  right  angles  to  them,  Tiiis  causes  a  deformity  in  sliape  of  the 
skull  or,  if  more  general,  a  small  size  (microcepJudus)  of  the  skull 
which  may  bo  the  cau.se  or  the  result  of  arrested  brain  development  or 
idiocy.  If  it  be  the  cause  of  idiocy  microcephalus  calls  for  craniec- 
tomy to  allow  for  the  growth  of  the  brain.  Such  premature  ossifica- 
tion may  be  due  to  rickets. 


CONDTTroyS  DEPENDiyCi  rPOX  ERRORS  OF  DKVKLOPM EST.  27 

The  sutures  may  assist  slightly  to  break  tiie  force  of  sliocks  and 
diminish  the  liability  of  fracture,  hence  the  latter  would  seem  more 
likely  to  follow  a  slight  injury  after  the  closure  of  the  sutures,  which 
occurs  at  varying  })eriods  after  middle  life.  This  closure  begins,  as 
in  the  long  bones,  at  the  end  of  the  suture  last  ossified,  /.  r.,  near  the 
fontnnelles  and  occurs  lirst  in  the  sagittal,  last  in  the  squamous  suture. 
It  is  said  to  begin  when  the  weight  of  the  brain  ceases  to  increase  and 
may  be  complete  by  the  age  of  80  (Tillaux). 

The  M^orinldn  honen  occur  in  varying  numbers  and  sizes  along  the 
sutures,  most  often  in  the  lambdoid  suture,  and  may  be  mistaken  for 
fragments  due  to  fracture.  One  of  these  bones,  the  cpiptcric  bone,  is 
found  at  the  pterion  and  usually  joins  the  great  wing  of  the  sphenoid, 
of  which  it  may  be  thought  to  be  a  broken  fragment.  It  may  be  met 
with  in  trephining  for  the  middle  meningeal  artery. 

In  craniofahes,  ascribed  to  rickets  or  inherited  syphilis,  the  skull 
is  deformed  by  the  premature  ossification  of  the  sutures,  the  occiput  is 
flattened  by  the  pressure  of  the  heavy  head  resting  largely  on  this 
part,  and  the  upper  ]iart  of  the  occipital  and  adjacent  jiarts  of  the 
parietal  bones  are  thickened,  with  here  and  there  a  thinning  on  the 
inner  surface,  so  that  in  places  a  mere  shell  of  bone  or  an  entire 
absence  of  bone  may  exist. 

Conditions  Depending  upon  Errors  of  Development. — The 
frontal,  ]iarietal,  scpiamous  ])ortion  of  the  tem])oral  and  the  part  of  the 
occipital  al)ove  its  highest  curved  line  are  ibrmed  in  membrane,  the  base 
of  the  skull  in  cartilage.  The  entire  absence  of  that  part  formed  in 
membrane  is  occasionally  found  as  an  anomaly.  The  squamous  ]iortion 
of  the  occipital  bone  is  ossified  from  four  centers,  a  ]")air  above  the  highest 
curved  line  and  a  pair  below.  The  u])j)er  pair  may  form  a  separate 
bone,  the  inter  pari  vial  bone  of  the  lower  vertebrates,  and  the  suture 
between  this  and  the  part  below  should  not  be  mistaken  for  a  fracture. 
More  commonly  there  ])ersist  two  lateral  fissures,  as  at  birth,  or  median 
fissures  between  the  lateral  centers,  and  these  fissures  also  should  not 
not  be  mistaken  for  fractures. 

Certain  tumors  of  congenital  origin,  containing  cerebral  contents  and 
called  cephaloceles  or  "  cerebral  hernia?,"  occur  as  the  result  of  de- 
fective development.  They  are  usually  situated  in  the  median  line 
and  most  often  in  the  occipital,  next  in  frequency  in  the  naso-frontal 
region.  Occipital  cephaloceles  generally  occur  through  a  median  fissure 
in  the  occipital  bone,  either  above  or  below  the  external  occipital  pro- 
tuberance ;  anterior  or  .^iincipital  ccj/lialocrlrs  through  the  naso-frontal 
suture.  INIore  rarely  such  tumors  occur  through  other  abnormal  aper- 
tures, especially  at  the  base  of  the  skull.  When  the  sac  of  a  ce}ihalo- 
cele,  which  is  formed  by  the  outer  cranial  membranes,  contains 
cerebro-spinal  fluid  alone  the  tumor  is  ealJiMl  a  meningocele,  when  it 
contains  brain  substance  an  encephalocele.  A  hydrencephalocele  is  an 
encephalocelc  containing  a  cavity  filled  with  lluid  which  is  often  con- 
nected with  the  cerebral  ventricles. 

The  parietal  fissure   is  a  narrow  gap  extending   from  the  jiarietal 


28  THE  HEAD   AND  NECK. 

eminence  to  the  sagittal  suture  about  an  inch  in  front  of  the  lambda. 
It  is  often  seen  about  the  fifth  month  of  foetal  life  as  a  cleft  between 
the  radiating  ossific  spicules  but  it  usually  closes.  When  present  on 
both  sides  the  lozenge-shaped  gap  is  known  as  the  sagittal  fontaneUe. 
The  fissure  should  not  be  mistaken  for  a  fracture. 

Construction  and  Lesions  of  the  Bones  of  the  Cranial  Vault. 

In  the  adult  these  bones  are  composed  of  compact  outer  and  inner 
tables  and  an  intervening  cancellous-like  layer,  the  diploe.  This  is  not 
present  in  children's  skulls  and  does  not  form  until  about  the  tenth 
year.  The  blood  supplii  of  these  bones  is  contained  largely  in  the  diploe 
which  receives  but  little  blood  from  the  vessels  of  the  pericranium, 
more  from  those  of  the  dura.  Some  of  the  consequences  of  this  we  have 
already  seen  (p.  22).  The  veins  of  the  diploe  empty  into  both  the 
dural  sinuses  and  the  surface  veins.  As  the  vessels  of  the  diploe  com- 
municate with  those  of  the  dura  and  the  dural  sinuses,  inflammatory 
lesions  of  the  bone  may  extend  to  the  sinuses  and  lead  to  sinus  throm- 
bosis, with  the  danger  of  pyaemia,  or  to  tlie  dura  and  cause  pachy- 
meningitis. 

Inflammatory  lesions  of  the  bones  commonly  lead  to  caries  or  necrosis, 
which  is  fairly  common  on  the  vault  of  the  skull  and  most  often  in- 
volves the  frontal  and  parietal  bones.  Owing  to  its  poorer  blood  sup- 
ply and  its  exposure  to  injuries  the  external  table  is  more  often 
involved  alone  than  the  internal  table.  Syphilis  and  tuberculosis  are 
not  uncommon  causes  of  caries  or  necrosis  of  these  bones,  many  cases 
result  from  injury,  especially  when  the  wound  is  infected,  and  but  few 
cases  are  spontaneous  or  idiopathic.  Besides  the  special  dangers, 
mentioned  above,  of  sinus  thrombosis  and  meningitis,  pus  may  collect 
between  the  bone  and  dura  and  cause  compression  of  the  brain,  but 
fortunately  the  collection  of  pus  here  is  not  common.  When  the 
disease  of  bone  involves  the  whole  thickness  of  the  skull  the  pulsa- 
tions of  the  brain  may  be  seen  or  felt  in  the  gap  produced.  Necrosis 
and  separation  of  extensive  areas,  even  of  the  entire  vault  (Saviard), 
has  been  reported.  A  peculiarity  of  necrosis  of  the  cranial  vault  is 
that  no  involucrum  is  formed  and  the  bone  is  not  reproduced.  As  a 
rule  stripping  up  of  the  dura  is  not  followed  by  necrosis. 

The  average  thickness  of  the  bones  of  the  cranial  vault  is  |  of  an 
inch  but  tliis  is  liable  to  wide  variation  in  different  parts  of  the  same 
skull  and  in  different  skulls.  Thus  it  is  very  thin  and  translucent  in 
the  squamous  portion  of  the  temporal,  the  anterior  inferior  angle  of 
the  parietal  and  in  the  inferior  or  cerebellar  fossse  of  the  occipital  squa- 
mosal ;  while  it  is  very  thick  at  the  occipital  protuberance,  the  mastoid 
process,  the  lower  part  of  the  frontal  bone,  and  along  the  ridges  that 
bound  the  grooves  for  the  superior  longitudinal,  the  lateral  and  occip- 
ital sinuses.  Again  the  inner  surface  of  the  cranium  is  marked  by 
depressions  or  grooves :  (1)  For  the  cerebral  convolutions,  (2)  for  the 
dural  sinuses,  (3)  for  the  meningeal  arteries  (especially  the  middle 


INFL.  1  MM  A  TOR  i '  L  h'SIOXS. 


29 


meningeal)  and  (4)  for  the  Pacchionian  bodies.  Hence  the  inner  and 
outer  tables  of  the  skull  are  not  parallel  with  one  another. 

These  facts  should  be  borne  in  mind  in  trephining.  The  pin  of  the 
trephine  should  not  be  made  to  penetrate  over  I  of  an  inch  and  in 
many  regions  ^-g  of  an  inch.  The  instrument  should  not  Ijc  applied 
over  the  course  of  the  sinuses,  over  the  position  of  the  frontal  sinuses 
(often  of  large  size  in  the  aged)  nor  over  the  position  of  the  middle 
meningeal  artery  unless  it  is  desired  to  expose  these  parts.  As  the 
suture  membrane  blends  with  tiie  dura  the  trephine  should  not  be 
applied  over  the  sutures  for  fear  of  wounding  the  dura.  From  time 
to  time  the  groove  made  by  the  trephine  should  be  tested  in  its  entire 
circumference  by  a  probe  to  see  if  it  is  through  where  the  bone  is  thin- 
nest. The  bleeding  in  a  trephine  wound  comes  almost  exclusively  from 
the  diploe. 

The  skull  presents  certain  stronger  ridges  or  buttresses  where  the 
bones  are  thicker  or  stronger  and  between  which  they  are  thinner  and 
more  readily  fractured.  These  buttresses  pass  from  the  vault  to  the 
base  at  the  foramen  magnum  and  serve  to  unite  the  two  parts  into 
one  solid  framework.  Thus  one  buttress  is  represented  by  the  median 
part  of  the  frontal,  the  ethmoid,  the  body  of  the  sphenoid  and  the 
basilar  portion  of  the  occipital.  This  antei-ior  buttress  is  continuous 
along  the  middle  line  of  the  vertex  with  the  posterior  buttress  which 
passes  through  the  occipital  protuberance  and  crest  to  the  foramen 
magnum.     Two  lateral  buttresses  exist,  the  anterior  represented  by  a 


Fig. 


rrcpanition  of  skull,  showiag  Uie  principiil  nrclu's  of  strength  or  biittres.-.i'8  of  resistance.     (Thomp- 
son, /.  <•.,  after  Uoi-iiiiAU  aiiil  1-'klizkt.) 


30  THE  HEAD  AND  NECK. 

ridge  of  bone  from  the  vertex  to  the  exterior  angular  process  of  the 
frontal  and  thence  through  the  great  wing  to  the  body  of  the  sphenoid, 
the  posterior  running  through  the  parietal  eminence,  mastoid  process, 
posterior  part  of  the  petrous  bone  and  the  jugular  process  to  the  occip- 
ital condyle/ 

The  bones  of  the  skull  and  the  skull  as  a  Avhole  are  elastic.  This 
elasticity  is  greater  in  the  infant  than  in  the  aged  but  even  the  adult 
skull  is  less  brittle  than  commonly  supposed.  The  yielding  character 
of  the  infant's  skull  is  shown  in  the  artificial  deformity  of  the  flat- 
headed  Indian,  produced  by  pressure,  and  it  has  been  asserted 
(Gueniot)  that  in  infants  considerable  deformity  may  be  produced  by 
the  weight  of  the  brain,  by  allowing  them  to  lie  always  upon  one  side. 
In  addition  in  the  infant  there  is  much  cartilage  and  membrane  be- 
tween the  bones.  Hence  the  skull  of  an  infant  is  not  easily  fractured. 
The  probable  eifect  of  a  blow  is  to  indent  the  skull.  During  delivery 
the  infant's  skull,  most  often  the  parietal  bone  (right  parietal  in  L.  O. 
A.  presentations)  may  be  flattened  by  pressure  against  the  sacral  prom- 
ontory or  by  the  use  of  the  forceps.  Though  a  hemorrhage  (cephal- 
hcematoma)  often  occurs  beneath  the  indented  area  real  fracture  is  rare. 

Fractures  of  the  Skull. 

Besides  its  elasticity  the  following  anatomical  conditions  of  the  skull 
lessen  its  liability  to  fracture,  the  rounded  form  favoring  glancing 
blows,  the  density  and  mobility  of  the  scalp,  the  composition  of  the 
skull  by  a  number  of  bones  separated  by  sutures  and  suture  mem- 
branes which  act  to  a  slight  extent  as  buffers,  and  the  mobility  of  the 
head  on  the  spine. 

Although  as  a  rule  the  entire  thickness  of  the  bone  is  involved  in 
fractures  of  the  skull  yet  the  external  table  alone  may  be  broken  or 
even  depressed  into  the  diploe  or  into  the  frontal  sinuses.  More 
rarely,  the  internal  table  may  be  fractured  without  injury  of  the  outer 
table.  The  latter  injury  can  only  rarely  be  diagnosed  by  the  symp- 
toms (vomiting,  convulsions,  etc.).  Fracture  of  the  internal  table 
alone  can  be  explained  and  illustrated  as  follows  :  An  injury  causing 
fracture  tends  to  flatten  out  the  skull  over  the  area  where  the  violence 
is  applied  and  is  like  bending  a  barrel  hoop  so  as  to  straighten  it. 
Like  the  barrel  hoop  it  gives  way  first  on  the  inner  or  concave  surface 
and  if  the  force  is  not  continued  this  surface  alone  may  be  broken. 
For  the  same  reason  in  complete  fractures  the  inner  table  is  fractured 
first.  In  addition  this  inner  table  is  most  extensively  fractured  in  most 
cases  for  (1)  it  is  thinner  and  more  brittle  (hence  called  the  "  vitreous 
table"),  (2)  the  force  as  it  travels  from  the  outer  table  through  the 
diploii  to  the  inner  table  passes  in  a  radiating  manner  so  as  to  reach 
the  inner  plate  in  a  more  diffused  form,  (3)  the  inner  table  is  a  ])art 
of  a  smaller  circle  and  (4)  as  the  force  tends  to  flatten  out  the  arch  the 

'Dupluy  and  Keclus,  Vol.  III.,  p.  461. 


FRACTURES  OF  THE  BASE.  31 

bony  particles  of  the  outer  table  are  forced  together  and  t;»ose  of  the 
inner  table  asunder. 

In  general,  fracture  of  the  vault  occurs  from  a  given  violence  when 
the  limit  of  its  ela.-ticity  is  excoccled,  as  illustrated  in  the  straightening 
of  a  barrel  hoop.  Fractures  of  tlie  vault  are  due  to  <Hr«rt  rioUnce  and 
usually  occur  at  the  point  where  the  force  is  apj>lied.  When  a  con- 
siderable force  is  applied  over  a  limited  area  this  area  of  the  skull 
is  usually  depressed.  When  it  is  applied  over  a  large  surface  (as  in 
falls  from  a  height)  the  entire  globe  of  the  skull  is  compressed  or  flat- 
tened in  the  direction  in  which  the  force  acts,  and  lengthened  or  pulled 
apart  in  a  direction  at  right  angles  to  this.  Two  forms  of  fracture 
may  result:  (1)  A  "compression  fracture"  at  the  point  where  the 
skull  is  pressed  together  by  the  direct  violence,  and  (^2)  a  "  bursting 
fracture  "  where  the  skull  has  been  lengthened  and  pulled  a.-under. 
The  latter  form  is  due  to  indirect  violence  and  occurs  more  often  at 
the  base  than  on  the  vault  of  tlie  skull. 

The  symptoms  and  danger  of  fractures  of  the  vault  depend  ver\' 
largely  on  the  coucomitant  l)rain  lesions  :  (1)  Concussion,  (2)  contu- 
sion of  the  brain,  (3)  intracranial  hemorrhage.  Fractures  of  the  (an- 
poral  region  are  in  general  more  serious  than  similar  fractures  of  the 
rest  of  the  vault,  for  the  middle  meninyeal  artery  is  often  injured  and 
the  resulting  hemorrhage  causes  compression  of  the  brain.  The  escape 
of  cerehro-spinal  fluid  from  a  fracture  of  the  vault  is  not  common, 
though  it  has  been  observed  in  compound  fractures  and  in  simple  frac- 
tures in  children  (resulting  in  a  fluctuating  tumor  beneath  the  scalp). 
It  indicates  injury  of  the  dura. 

It  is  interesting  to  note  how  the  construction  of  the  skull  resists  the 
fracturing  force  in  many  ways.  A  blow  on  the  vertex  in  the  parietal 
region  tends  to  drive  the  upper  borders  of  the  parietal  bones  inward 
and  the  lower  borders  outward.  The  latter  tendency  is  resisted  by 
the  overlapping  great  wing  of  the  sphenoid  and  the  scjuanious  bone. 
The  latter  is  buttressed  by  the  zygomatic  arch  and  this  in  turn  by  the 
malar  and  the  bones  of  the  face,  hence  the  pain  in  the  face  said  to  be 
felt  in  falls  or  blows  on  the  top  of  the  head.  When  the  frontal  suture 
exists  a  tendency  of  the  lower  part  of  the  frontal  bone  to  be  Ibrced 
outward  in  blows  on  the  median  parts  of  the  frontal  is  simihirly 
resisted  by  the  overlapping  arterior  inferior  part  of  the  parietal  and 
the  great  wing  of  the  sphenoid.  A  blow  on  the  upper  part  of  the  frontal 
bone  is  transmitted  to  the  parietal  on  which  this  ]>art  of  the  frontal 
bone  rests  owing  to  the  bevelling  of  the  upper  part  of  the  contuary  su- 
ture. Blows  on  the  occiput  are  less  safeguarded  by  anatonncal  arrange- 
ments, except  by  its  articulation  with  tlie  elastic  vertebral  column. 
Gaseous  tumors  beneath  the  scalp  have  been  described  as  a  sequel  to 
fractures  of  tiie  skidl  in  which  one  of  the  cavities  containing  air  has 
been  involved  in  the  fracture,  /.  c,  the  various  sinuses,  mastoid  cells,  etc. 

Fractures  of  the  base  may  be  due  to  (1)  direct  violence,  (2)  indi- 
rect violence,  and  (3)  extension  of  a  fracture  of  the  vault.  Fractures 
of  the  base  by  direct  viofencc  occur  in  ca.ses  where  a  foreign  body  is 


32  THE  HEAD  AND  NECK. 

forced  through  the  orbital,  nasal  or  pharyngeal  roof  or  through  the  nape 
of  the  neck  in  the  posterior  fossa.  They  are  not  common.  One  form  of 
fracture  of  the  base  by  indirect  violence  is  illustrated  by  the  fracture  of 
the  cribriform  plate  of  the  ethmoid  or  the  orbital  plate  of  the  frontal  by 
a  blow  on  the  root  of  the  nose  or  the  lower  part  of  the  frontal  bone  ; 
and  by  the  fracture  of  the  glenoid  fossa  by  the  condyle  of  the  jaw  driven 
violently  upward,  as  in  fells  or  blows  on  the  chin.  In  this  manner  the 
condyle  has  been  actually  thrust  into  the  cranial  cavity  (Chassaignac). 
Again,  in  falls  upon  the  buttocks,  less  often  upon  the  feet  or  knees, 
the  force  has  been  transmitted  along  the  vertebral  column,  especially 
when  it  is  kept  rigid  by  muscular  action,  and  has  resulted  in  the  frac- 
ture of  the  base  in  the  occipital  region,  often  in  a  "  ring  fracture " 
around  the  foramen  magnum.  A  similar  fracture  may  possibly  result 
from  a  blow  on  the  head  just  as  the  handle  of  a  hammer  may  be 
driven  in  either  by  a  blow  on  the  end  of  the  handle  or  by  one  on  the 
head  of  the  hammer. 

The  mechanism  of  the  majority  of  fractures  of  the  base  has  been 
much  discussed.  The  former  theory  that  many  were  the  results  of 
contrecoup,  or  a  focusing  of  the  force  at  the  opposite  pole  to  that 
struck,  has  been  abandoned.  Possibly  a  very  few  cases  may  be  so 
explained  though  perhaps  better  as  "  compression  "  or  "  bursting"  frac- 
tures. Aran  and  others  showed  that  very  many  fractures  of  the  base 
were  fractures  by  irradiation,  i.  e.,  the  result  of  fractures  of  the  vault 
spreading  to  the  base  by  the  shortest  route  irrespective  of  the  sutures, 
hence  fractures  of  the  frontal  region  spread  to  the  anterior  fossa,  those 
of  the  parietal  region  to  the  middle  fossa  and  those  of  the  occipital 
region  to  the  posterior  fossa.  This  was  especially  the  case  in  linear 
fissures,  the  result  of  diffused  violence,  as  in  falls  upon  the  head.  In 
general  when  the  violence  is  not  excessive  Felicet  found  that  these  frac- 
tures seem  to  run  in  the  weaker  areas  between  the  ridges  or  buttresses 
(see  p.  29).  These  explanations  do  not  fit  all  cases  or  even  the  majority, 
as  well  as  does  that  of  "compression"  and  •'  bursting"  fractures  (see 
p.  31).  As  seen  above  the  latter  are  indirect  fractures  and  probably 
comprise  most  of  the  fractures  of  the  cranial  base.  Fractures  due  to 
bursting  (/.  c,  most  fractures  of  the  base)  run  parallel  to  the  axis  of 
pressure,  those  due  to  compression  run  at  right  angles  to  this  axis. 
Fractures  of  the  base  run  in  the  direction  of  the  violence  that  inflicts 
the  injury  or  parallel  to  it.  Hence,  given  the  direction  of  the  force 
and  the  point  struck,  we  can  fairly  well  predict  the  course  of  a  fracture 
of  the  base.  Bursting  fractures  are  most  likely  to  occur  where  the 
skull  is  weakest  which  is  at  the  base,  owing  to  the  numerous  foramina, 
etc.  (Figs.  3  and  4). 

In  fractures  of  the  base  there  is  usually  a  discharge  of  blood  and 
often  o{  cerebrospinal  fluid  externally.  In  the  majority  of  basal  frac- 
tures the  petrous  bone  is  involved  and  especially  that  part  which  is 
weakest,  which  lies  in  the  plane  passing  through  the  middle  ear,  the 
internal  ear  and  the  internal  auditory  meatus.  In  such  cases  the  tym- 
panic membrane  is  commonly  ruptured  and  this  allows  of  the  escape 


PLATE    1 


FIG.  3. 


FIG.  4. 


Illustrating  lines  of  iDursting  force  in  basal  fractures.     (Wahl. 


FIG. 


SUP.    LONGITUDINAL      ,  n  p.    LONGITUDINAL 


SPHENOPA 
RIETAL 
SINUS 


INF.    PETRO- 
SAL   SINUS 

SUP.    PETRO- 
SAL   SINUS 


Interioi'  of  the  base  of  the  skull  covered  by  dura,  showing 
the  sinuses,  nerve  exits  and  tentorium.  Ci-anial  nerves  are 
numbered  in   Roman  figures.     (Merkei.) 


THE   CEREBRAL   MEMBRANES.  33 

of  blood  from  the  ear,  a  symptom  so  common  in  fractures  of  this  region 
of  the  base.  This  blood  may  be  derived  from  the  vessels  of  the  tym- 
panum and  its  membrane  or  from  an  intracranial  source,  sometimes 
from  the  rupture  of  one  of  the  sinuses  about  the  petrous  bone.  If  the 
membrane  is  not  ruptured  the  blood  may  pass  through  the  Eustachian 
tube  and  escajw?  at  the  nose  or  mouth.  In  addition  to  bleeding  from 
the  ear  the  flow  of  cerebro-spinal  fluid  is  sometimes  observed.  This 
occurs  when  the  dura  and  arachno  d,  or  their  tubular  prolongation  in 
the  internal  auditory  meatus,  are  torn  by  the  fracture,  which  connects 
the  subarachnoid  space  with  the  tympanum  whose  membrane  is  lac- 
erated. A  free  .sorouH  dlscharf/c  may  (teeur  from  the  ear  after  an  injury 
to  the  head,  without  fracture.  It  escapes  through  a  rupture  in  the 
tympanic  membrane  and  may  be  derived  from  the  mastoid  cells  or  it 
may  be  blood  serum. 

In  fractures  of  the  anterior  fossa  the  blood  escapes  into  the  nose, 
mouth  or  orbit.  In  the  latter  case  it  produces  a  subconjunctival 
ecchymosis,  rarely  an  exophthalmus.  Bleeding  into  the  nose  may  run 
back  into  the  mouth  and  in  bleeding  either  into  the  mouth  or  nose 
the  blood  may  be  swallowed  and  subsequently  vomited.  When  bleed- 
ing from  the  nose  or  mouth  occurs  as  the  result  of  a  basal  fracture  the 
latter  involves  the  cribriform  plate  or  the  body  of  the  sphenoid.  In 
bleeding  from  the  nose  the  greater  part  of  the  blood  probably  comes 
from  the  torn  mucosa  of  the  nasal  roof.  If  there  is  a  discharge  of 
cerebro-spinal  fluid  from  the  nose  there  must  be  a  laceration  of  the 
nasal  mucosa  and  of  the  dura  and  arachnoid.  In  fracture  of  the  base 
in  the  posterior  fossa  of  the  skull  the  blood  may  appear  as  an  extrav- 
asation about  the  mastoid  process  or  the  nape  of  the  neck. 

The  symptoms  and  serious  nature  of  basal  fractures  depend  upon 
the  eoneoinitant  intracranial  lesions.  Meninejitis,  due  to  infection  of 
a  fracture  of  the  base  which  opens  into  a  cavity  connected  with  the 
air,  is  rare  as  a  cause  of  death  as  compared  with  the  intracranial  lesions 
due  to  the  injury.  The  base  of  the  skull  is  rather  inaccessible  to  oper- 
ations on  accouut  of  its  location. 

Owing  to  a  lack  of  reparative  vitality,  repair  after  fractures  of  the 
skull  is  very  slow  and  bony  union  occurs  only  when  the  fragments  are 
separated  by  a  very  small  interval.  The  new  bone  is  produced  mostlv 
by  the  diploe  and  more  by  the  dura  than  by  the  pericranium.  When 
there  is  any  considerable  loss  of  substance  the  oj^ening  is  not  filled  in 
with  bone  save  for  a  narrow  strip  around  the  edge.  After  recovery 
from  diastasis  in  a  child  the  growth  of  bone  is  not  interfered  with. 


THE    CONTENTS    OF    THE    CRANIUM. 

The  Cerebral  Membranes. 

The  tough  fibrous  dura  may  I)c  dividid  into  an  outer  periosteal  layer 
and   an   inner  or   supporting   layer.      This  corresponds  to   its   twofold 
function,  on   the  one   hand   as  an  endosteum   and   on   the  other  as  a 
3 


34  THE  HEAD  AND   NECK. 

protective  covering  of  the  brain.  These  layers  are  inseparable  over 
the  greater  part  of  their  extent,  but  the  inner  separates  from  the  outer 
layer  to  form  the  cranial  sinuses  and  the  processes,  like  the  falx  and 
tentorium,  which  help  to  support  and  protect  the  brain.     (See  Fig.  1.) 

The  adhesion  of  the  outer  layer  to  the  bone  increases  with  age  and  in 
chronic  inflammation  of  the  bone  or  the  dura,  but  is  less  intimate  in 
acute  inflammations.  It  varies  in  different  parts  of  the  skull.  Over 
the  vertex  and,  according  to  Tillaux,  particularly  in  the  temporal 
fossae  the  dura  is  comparatively  loosely  attached,  except  along  the 
sutures  where  it  is  more  adherent.  This  loose  attachment  allows  a 
probe  to  be  passed  a  considerable  distance  between  the  bone  and  the 
dura,  if  the  sutures  are  avoided,  and  large  extravasations  of  blood  or 
pus  may  occur  here  and  lead  to  compression  of  the  brain.  Such  ex- 
travasations are  often  limited  to  one  bone  by  the  adhesion  along  the 
suture  lines,  but  not  necessarily,  especially  in  the  case  of  purulent  col- 
lections. The  adhesion  of  the  dura  to  the  bone  is  largely  due  to  the 
passage  of  small  blood  vessels  from  the  meningeal  vessels  of  the  former 
to  nourish  the  bone.  The  bone  can  live  however  if  the  dura  is  stripped 
off  and  after  loss  of  bone  the  loss  is  not  repaired  by  the  dura.  In  the 
majority  of  traumatic  cases  the  cause  of  cerebral  compression  lies  out- 
side the  dura  in  the  epidural  space  or  is  due  to  the  bone  itself. 

As  pointed  out  by  Sir  C.  Bell  the  clara  of  the  vault  may  be  separated 
from  fJtehonehy  a  blow  and  if  this  occurs  during  life  the  corresponding 
epidural  area  is  occupied  by  a  clot  from  the  rupture  of  many  small  ves- 
sels that  pass  from  the  dura  to  nourish  the  bone.  If  a  larger  vessel  is 
ruptured  the  hemorrhage  may  gradually  strip  off  more  and  more  of  the 
dura  so  that  a  clot  is  formed  which  gradually  causes  local  or  general 
symptoms  of  compression.  The  stripping  up  of  the  dura  may  be  dem- 
onstrated on  the  cadaver  by  striking  a  blow  and  then  injecting  the 
blood  vessels. 

The  vessel  which  by  its  rupture  is  most  often  (Sofo  more  or  less) 
the  cause  of  serious  or  fatal  epidural  compression  is  the  middle  meningeal 
artery,  in  the  temporal  fossa.  This  is  the  cause  of  the  more  serious 
results  of  fracture  in  this  region.  This  vessel  is  for  the  most  part 
closely  wrapped  by  the  outer  layer  of  the  dura  so  that  it  is  ruptured 
in  any  tear  of  the  latter,  in  fracture  of  the  skull.  It  may  also  be  torn 
without  fracture,  for  in  the  great  wing  of  the  sphenoid  and  the  antero- 
inferior angle  of  the  parietal  it  is  often  lodged  in  a  bony  canal  or  a 
groove  whose  open  side  is  smaller  than  that  of  the  artery  so  that  if  by 
a  blow  the  dura  is  here  stripped  from  the  bone  the  artery  is  torn  at 
the  point  where  the  canal  or  deep  groove  prevents  it  from  being 
stripped  back  with  the  dura.  When  after  a  blow  over  the  position  of 
this  vessel  symptoms  of  compression,  not  present  at  first,  come  on 
after  an  interval  and  gradually  increase  ruj)ture  of  this  artery  or  some 
of  its  branches  is  probable.  As  it  lies  in  ])art  over  the  cortical  motor 
area  motor  para/i/ses arc  likely  to  occur  from  local  compression.  As  such 
cases  get  progressively  worse  and  end  fatally,  operation  with  turning  out 
the  clot  and  plugging  or  tying  the  vessel  is  imperatively  demanded. 


THE  SUBDURAL  SPACE.  35 

Hence  the  importance  of  knowing  the  position  and  course  of  this 
vessel.  (See  Fig.  7.)  Tlie  trunk  of  the  artery  passes  outward  and 
forward  for  a  short  ijut  variable  distance  from  the  foramen  spinosum, 
through  which  it  enters  the  skull.  It  has  tv)o  main  branches  of  which 
the  larger  (interior  one  runs  upward  and  forward  across  the  antero- 
inferior angle  of  the  parietal  bone  and  continues  in  a  groove  a  little 
behind  the  coronal  suture,  giving  off'  branches  which  run  upward  and 
backward.  Tne  posterior  hranch  runs  backward  across  the  sfjuamous 
bone  and  then  upward  and  backward  over  the  ])osterior  part  of  the 
parietal  bone.  Although  it  may  be  possible  by  a  single  trephine  open- 
ing to  expose  both  branches  of  the  artery  yet  such  an  opening  must  be 
low  down  on  the  temporal  fossa  and  below  the  common  site  of  injury 
of  the  vessel,  which  is  in  the  anterior  branch  near  the  pterion,  where 
the  groove  is  often  very  deep  or  converted  into  a  canal.  When  the 
groove  is  so  arranged  fracture  here  without  laceration  of  the  artery  would 
hardly  be  possible  and  this  thin  part  of  the  skull  is  particularly  liable  to 
be  fractured.  If  we  trephine  and  ligate  the  artery  too  low  an  anasto- 
motic branch  from  the  orbit  may  join  the  artery  above  the  jioint  of  liga- 
tion and  below  the  ])oint  of  rupture  and  thus  continue  the  hemorrhage. 
To  expose  the  anterior  branch  of  the  middle  meningeal  artery  a  trephine 
opening  or  iK)ne  flap  is  made  just  behind  the  pterion  (see  p.  20)  ;  or 
two  fingers'  breadth  above  the  zygoma  and  a  thumb's  breadth  behind 
the  frontal  process  of  the  mnlar  bone  (Vogt) ;  or  3-4  cm.  behind  the 
latter  point  on  a  level  with  the  supraorbital  margin  (Kronlein).  As 
the  artery  lies  enclosed  in  the  firm  dura  or  in  the  bone  the  chance  of 
spontaneous  arrest  of  bleeding  is  slight. 

At  the  hui^e  of  the  skull  the  dara  is  closely  adherent  to  the  bone  so 
that  epidural  extravasation  can  scarcely  occur,  and  in  fractures  of  the 
base  the  dura  is  likely  to  be  torn,  allowing  the  escape  of  cerebro-spinal 
fluid.  The  dura  smoothes  over  some  of  the  inequalities  of  the  base 
and  passes  out  through  the  foramina  of  the  skull  with  the  cranial 
nerves  to  become  continuous  with  the  nerve  sheaths  as  well  as  with 
the  pericranium  on  the  outer  surface  of  the  skull.  Its  inner  surfaceh 
smooth  owing  to  the  layer  of  flat  endothelial  cells  which  covers  it. 

The  subdural  space,  or  the  potential  interval  between  the  dura  and 
the  arachnoid,  contains  a  small  amount  of  //m/^/  and  probably  serves  to 
prevent  friction  of  the  surface  of  the  brain  during  its  movements,  like 
the  pleural  and  other  serons  sacs.  The  hemorrhage  m  pachymeninr/itis 
hemorrh(/r/ica  occurs  in  this  space,  into  which  a  considerable  effusion 
may  occur  without  marked  sym{)toms  on  account  of  its  wide  diffusion. 
Following  an  injury  extravasations  of  l)lood  into  this  space  are  very 
common  and  the  blood  so  effused  is  liable  to  shift  its  position  and  per- 
haps suddenly  cause  dangerous  symptoms  by  gravitating  to  the  vicinity 
of  the  pons,  cerebellum  and  medulla.  Similarly,  during  operations 
upon  the  brain,  l)lood,  pus  or  irrigating  fluid  may  enter  this  space  and 
gravitate  toward  the  medulla  or  sj)inal  ciinal.  Hence  care  should  be 
taken  in  evacuating  and  irrigating  cerebral  abscesses  to  avoid  the  pas- 
sage of  the  fluid  into  this  space  and  to  secure  its  Escape  extracranially. 


36  THE  HEAD  AND  NECK. 

The  subdural  space  communicates  with  the  abundant  lymphatics  of  the 
dura  and  from  the  latter  pathogenic  organisms  may  invade  this  space. 
Normally  the  inner  surface  of  the  dura  is  not  connected  with  the 
arachnoid  except  by  a  few  and  very  delicate  processes,  hence  on  open- 
ing the  dura  any  adhesions  which  prevent  the  probe  or  finger  passing 
freely  between  it  and  the  brain  are  pathological. 

The  fibrous  folds  formed  by  the  reflection  of  the  inner  or  proteotive 
layer  of  the  dura  (falx  cerebri,  tentorium  cerebelli,  etc.)  are  of  little 
surgical  interest  but  they  are  important  in  preventing  the  compression 
of  the  two  hemispheres  by  each  other,  and  of  the  isthmus  of  the  brain 
and  the  cerebellum  by  the  cerebrum. 

The  sinuses  of  the  dura  are  formed  by  the  separation  of  the  inner 
from  the  outer  layer  on  the  surface  or  by  the  separation  of  two  folds  of 
the  inner  layer  on  the  folds  or  processes  of  the  dura.  (See  Fig.  1 .)  They 
are  lined  by  an  epithelial  layer  continuous  with  the  inner  layer  of  the 
veins.  Their  walls  are  rigid  and  non-collapsible  so  that  when  wounded 
bleeding  is  not  spontaneously  arrested.  Certain  sinuses  are  of  especial 
surgical  interest  and  their  position  is  of  importance  because  in  certain 
operations  we  wish  to  avoid  them,  in   others  to  expose  them   (Fig.  5). 

The  superior  longitudinal  or  sagittal  sinus  extends  in  the  median 
line  from  the  foramen  caecum  anteriorly  to  the  torcular  Herophili, 
opposite  the  external  occipital  protuberance,  posteriorly.  As  the  tor- 
cular is  usually  to  the  right  of  the  median  line  the  posterior  and  larger 
part  of  the  sinus  is  also  rather  more  to  the  right  of  the  median  line. 
Through  the  foramen  ccecum  it  communicates  with  the  veins  of  the 
nasal  mucosa,  hence  epistaxis  may  directly  relieve  cerebral  congestion 
and  infective  organisms  from  lesions  of  the  nasal  septum  may  thus 
enter  the  sinus.  It  also  communicates  with  the  scalp  by  the  emissary 
veins  passing  through  the  parietal  foramina  so  that  it  may  become  in- 
fected from  erysipelas  or  other  septic  diseases  of  the  vertex.  This 
sinus  receives  the  veins  from  the  median  and  upper  surface  of  the 
cerebrum  and  communicates  with  the  basal  sinuses  through  the  anas- 
tomosis of  the  superior  cerebral  with  the  middle  cerebral  and  Sylvian 
veins.  As  the  blood  of  the  superior  longitudinal  sinus  usually  passes 
into  the  right  lateral  sinus  and  that  of  the  straight  sinus  into  the  left 
lateral  sinus,  it  follows  that  the  right  lateral  sinus  is  usually  the  larger 
and  receives  the  blood  from  the  surface  of  the  brain  while  the  left 
sinus  drains  the  central  ganglionic  portions. 

The  course  of  the  lateral  sinuses  is  represented  by  a  line  from  the 
external  occipital  protuberance  to  the  upper  margin  of  the  external 
osseous  meatus  or  the  base  of  the  mastoid  process.  (See  Fig.  9.)  It  is 
usually  slightly  convex  upwards  and  crosses  the  asterion,  from  whence 
to  the  jugular  foramen  it  is  called  the  sigmoid  sinus,  on  account  of  its 
crooked  S-shaped  course.  The  sharp  downward  and  inward  bend,  or 
gemi,  of  the  sigmoid  sinus  on  the  mastoid  bone  is  convex  forward.  It 
reaches  forward  to  a  point  \  to  \  of  an  inch  behind  a  coronal  plane 
through  the  posterior  border  of  the  external  osseous  meatus  and  is  on 
a  level  with  the  upper   part  of  the  meatus.     The  genu  on  the  right 


THE  CAVERSorS  SIXUS.  37 

side  extends  slightly  further  forward  and  outward  than  on  the  left  and 
this  fact  may  possibly  account  for  the  supposed  greater  frequency  of 
intracranial  complications  following  otitis  media  on  the  right  side. 
The  genu  of  the  sigmoid  sinus  receives  groups  of  veins  from  the  tym- 
panum and  the  mastoid  antnnii  and  cells,  through  which  infection  may 
spread  to  the  sinus  and  cause  thrf)nil)osis. 

The  course  of  the  sigmoid  sinus,  where  it  is  accessible  to  opera- 
tion, corresponds  to  two  lines  ;  the  upper  and  more  superficial  part  to 
the  posterior  fj  of  a  line  from  the  asterion  to  the  up])er  margin  of  the 
external  osseous  meatus,  the  vertical  part  to  the  upper  ^^  of  a  line 
from  the  parieto-squamo-mastoid  junction  (or  the  middle  of  the  base  of 
the  mastoid)  to  the  tip  of  the  mastoid  (see  also  Fig.  7).  An  opening 
may  be  made  into  the  genu,  the  part  of  the  sinus  most  often  affected, 
at  a  point  half  an  inch  behind  the  posterior  wall  of  the  bony  auditory 
canal  between  the  levels  of  its  roof  and  floor.  Between  these  levels 
the  upper  and  more  superficial  part  of  the  sinus  is  |  inch  (sometimes 
as  little  as  ^v,  inch)  from  the  surface  and  is  thus  more  superficial  than 
the  antrum,  while  its  lower  ])art  lies  more  deeply. 

The  sigmoid  sinus  is  connected  with  the  surface  veins  through  two 
emissary  veins,  the  mastoid  and  the  posterior  condylar.  The  mastoid 
vein  joins  the  occipital  and  through  this  the  deep  cervical,  or  occasion- 
ally it  joins  the  posterior  auricular.  It  may  become  thrombosed  from 
sinus  thrombosis  or  its  foramen  may  give  vent  to  extradural  pus  in  the 
cerebellar  fossa.  The  posterior  condylar  vein  is  the  larger  and  more 
constant  of  the  two,  contrary  to  what  is  usually  stated.  It  joins  the 
deep  veins  at  the  back  of  the  neck  and  its  foramen  may  drain  extra- 
dural pus  in  the  bottom  of  the  cerebellar  fossa,  setting  up  a  deep  in- 
flammation or  abscess  in  the  up])er  part  of  the  back  of  the  neck  which 
causes  swelling  and  tenderness  on  pressure  here.  These  two  emissary 
veins  and  the  occipital  sinus  may  convey  infective  matter  from  the  lateral 
and  sigmoid  sinuses  to  the  heart  and  lungs  so  that  ligation  of  the  internal 
jugular  vein  does  not  afford  complete  protection  against  this  accident. 

The  u])jier  and  posterior  end  of  the  sigmoid  sinus  lies  at  the  junction 
of  the  n)iddle  and  anterior  thirds  of  the  cerebellum  so  that  the  latter 
may  be  exposed  in  front  of  the  sinus,  though  preferably  behind  it. 
The  pdriefo-sfjiKiino-iiuistoid  Juitcfion  corresponds  to  the  point  where  the 
superior  ])etrosal  joins  the  sigmoid  sinus  and  where  the  upper  border 
of  the  jK'trous  joins  the  mastoid  bone. 

The  cavernous  sinus  extending  from  the  sphenoidal  fissure  to  the 
apex  of  the  jx'trous  bone  receives  and  is,  as  it  were,  the  continuation 
of  the  oj/hf/Ki/iiiic  vein.  The  fact  that  the  latter  anastomoses  with  the 
facial  through  the  nasal  vein  exjilains  why  an  infiammation  near  the 
facial  vein,  like  a  carbuncle  of  the  upper  lip,  is  more  serious  than  a 
similar  condition  on  the  lower  lip,  as  the  former  may  extend  along  the 
veins  and  set  up  a  cavernous  sinus  thrombosis.  This  sinus  also  com- 
municates with  the  pteri/(/oi(}  p/exiis  by  means  of  the  ophthalmic  and 
Vesalian  veins  through  which  infective  matter  may  pass  from  one  to 
the  other.     The  intimate  relation  between  the  carotid  artery  and  the 


38  THE  HEAD  AND   NECK. 

cavernous  sinus  accounts  for  the  fact  that  arterio-venons  aneurism  has 
followed  injury  of  these  parts.  In  such  cases  the  orbital  cavity  is 
distended  with  a  pulsating  tumor  consisting  of  the  dilated  o]>hthalmic 
veins  which  protrude  the  eyeball. 

As  the  dural  sinuses  are  rigid,  non-collapsible,  ever-patent  tubes  and 
the  jugular  veins  into  which  they  empty  are  alternately  distended  in 
expiration  and  collapsed  in  inspiration  this  aspiration  would  involve 
the  sinuses  unless  there  were  some  inechaniwi  to  prevent  it.  If  the 
sinuses  were  thus  aspirated  and  the  blood  of  the  brain  suddenly  pro- 
pelled forward  to  compensate  for  that  withdrawn  there  would  be  a 
disturbance  of  brain  function,  a  sudden  faintness  or  lack  of  brain 
power  on  each  deep  inspiration.  The  entire  sinus  arrangement  ensures 
a  regular  even  flow  as  seen  in  the  entrance  of  the  middle  and  posterior 
cerebral  veins  obliquely  into  the  longitudinal  sinus  against  its  current, 
thus  damming  it  back,^  and  especially  in  the  traj)-/ike  passage  of  the 
sigmoid  sinus  into  the  jugular  bulb.  The  roof  of  the  lowest  portion, 
near  the  end  of  the  sigmoid  sinus,  is  on  or  below  the  level  of  the  floor 
of  its  entrance  into  the  jugular  bulb  and  the  roof  of  the  latter  is  much 
above  the  whole  of  the  lower  end  of  the  sigmoid  sinus  so  that  an  ar- 
rangement like  a  plumber's  trap  is  formed  to  prevent  aspiration  of  the 
sinus.  This  aspiration  is  further  prevented  by  the  entrance  of  the 
inferior  petrosal  sinus  into  the  jugular  bulb  so  that  this  sinus  alone,  if 
any,  would  feel  the  eftects  of  aspiration.  Furthermore  by  pouring  its 
blood  into  the  jugular  bulb  from  a  large  reservoir,  the  cavernous  sinus, 
there  is  no  absolute  collapse  of  the  internal  jugular  with  the  conse- 
quent difficulty  in  reestablishing  the  flow. 

Between  the  two  layers  of  the  dura  and  occupying  a  depression  on 
the  iipj^er  surface  of  the  apex  of  the  petrous  bone  and  the  adjoining 
cartilage  filling  the  middle  lacerated  foramen,  is  the  crescentic  Gasserian 
ganglion.  This  with  the  roots  of  two  of  its  branches,  the  superior  and 
inferior  maxillary  divisions  of  the  fifth  nerve,  is  sometimes  removed 
for  intractable  neuralgia.  The  best  method  of  operation  is  the  osteo- 
plastic Hartley-Krause  method  by  which  an  ii^-shaped  flap  of  l)one  and 
soft  parts,  having  its  base  on  a  level  with  the  zygomatic  arch,  is  turned 
down  exposing  the  dura.  The  latter  is  then  se])arated  from  the  floor 
of  the  middle  fossa  of  the  skull  until  the  two  branches  named  above 
are  ex])osed  and  traced  up  to  the  ganglion.  To  expose  the  latter  the 
outer  layer  of  the  dura  must  be  divided.  Its  close  relation  to  the  in- 
ternal carotid  artery  and  the  cavernous  sinus  as  well  as  to  the  middle 
meningeal  artery  must  be  borne  in  mind,  and  the  latter  artery  may  also 
give  trouble  in  the  bone  flaj).  A  small  vessel  nc('onij)anying  the  infe- 
rior maxillary  nerve  has  occasionally  caused  troublesome  hemorrhage. 

The  delicate  arachnoid  is  closely  applied  to  the  pia,  over  the  top  and 
sides  of  the  head,  l)ut  does  not  dip  in  between  the  convolutions.  The 
subarachnoid  space  is  scarcely  recognizable  over  the  upper  surface, 
though  present,  while  over  the  posterior  two-thirds  of  the  base  (in  the 

'  For  further  interesting  particulars  consult  Macewen,  Diseases  of  tlie  Brain  and 
Spinal  Cord,  p.  35. 


THE  BRAIN.  39 

posterior  and  middle  fossae)  it  is  large  and  contains  the  larger  part  of 
the  cerebral  cerebro-spinal  fluid.  The  latter  serves  as  a  water  bed  for 
the  important  i)arts  of  the  brain  resting  npon  it,  while  the  less  im- 
portant frontal  lobes  rest  directly  upon  the  bone,  covered  by  dura. 
This  arrangement  of  the  fluid  protects  the  posterior  parts  of  the  base 
of  the  brain  from  the  effects  of  injury,  either  direct  or  by  contrecoup, 
while  the  base  of  the  frontal  lobes  is  not  infrequently  injured  by  com- 
ing in  violent  contact  with  the  irregular  orbital  plates.  The  cerebro- 
spinal fluid  differs  from  blood  serum  in  its  very  small  percentage  of 
albumin.  The  cerebral  and  spinal  subarachnoid  spaces  communicate 
freely  with  each  other  through  the  foramen  magnum  and  with  the 
cavity  of  the  cerebral  vesicles  through  \.\\e  Joraiiwn  of  Mdfjcndic,  in  the 
lower  ])art  of  the  roof  of  the  fourth  ventricle.  Hence  the  cerebro- 
spinal fluid  may  also  serve  to  equalize  the  intra-cranial  pressure  by 
being  ])artly  forced  out  from  the  ventricles  through  the  foramen  of 
Matrendie  when  the  nerve  centers  in  the  walls  of  the  ventricles  are 
congested  and  down  into  the  spinal  canal  if  the  general  intracranial 
pressure  is  increased,  as  in  cases  of  congestion  from  irregularities  in 
the  blood  circulation.  In  case  the  foramen  of  Magendie  is  blocked  by 
a  tubercular  deposit  or  the  })ressurc  of  a  cerebellar  tumor  fluid  may 
accumulate  in  the  ventricles  and  result  in  internal  hydrocephalus. 
Lumbar  puncture  as  a  diagnostic  and  therapeutic  measure  depends 
upon  this  intercommunication  and  flow  of  the  cerebro-spinal  fluid  from 
one  part  to  another.  In  operations  on  the  base  of  the  brain,  or  on  a 
spina  bifida,  etc.,  the  draining  away  of  cerebro-spinal  fluid  may  deprive 
the  medulla  of  its  water  bed  and  cause  it  to  rest  directly  upon  bone,  so 
as  even  to  interfere  with  its  functions. 

The  subarachnoid  space  is  continued  around  the  optic  nerve  in  the 
orbit  where  it  may  even  become  cystic  by  being  shut  oflP  from  the  rest 
of  the  space.  Over  the  other  cranial  nerves  the  arachnoid  is  continued 
only  a  short  distance  and  becomes  fused  with  the  nerve  sheath,  but 
fluid  injected  into  the  subarachnoid  or  subdural  space  passes  along  the 
nerves  as  far  as  the  limbs.  Without  any  direct  channel  fluid  may  also 
pass  from  the  subarachnoid  to  the  sul)dural  space  and  even  from  the 
former  into  the  longitudinal  sinus  through  the  Pacchionian  bodies, 
which  are  arachnoid  villi  and  project  in  some  cases  into  the  sinus. 
The  ara(!hnoid  is  not  considered  as  an  entity  in  the  pathology  of 
meningeal  inflammation. 

The  intimate  relations  of  the  pia  and  brain,  the  former  closely  eover- 
ing  the  surface  and  dipping  into  the  substance  of  the  brain  as  an 
investment  of  its  blood  vessels,  siiows  that  a  certain  degree  of  encepha- 
litis is  necessary  with  lepto-meningitis.  The  li/injilidfics  of  the  pia 
open  into  the  subarachnoid  space. 

I./ittle  need  be  said  of  the  brain  itself,  apart  tVom  the  facts  of  cere- 
bral localization  and  cranio-cerebral  topography,  except  that  surgically 
it  is  a  large  soft  vascular  mass  that  do(\s  not  completely  All  the  cranial 
cavity  and  hence  may  be  injured  i)y  shaking  or  by  being  thrown  about 
and  collidin<r  witii  the  cranial  walls. 


40  THE  HEAD  AND   NECK. 

As  a  result  of  injuiy  to  the  head,  symptoms  of  shock  may  be  present 
which  are  known  as  concussion  of  the  brain.  It  is  supposed  that  no 
visible  lesions  of  the  brain  are  thereby  produced  and  the  symptoms 
do  not  long  persist.  From  a  more  severe  injury  the  soft  brain,  espe- 
cially its  cortex,  may  suffer  contusion  (or  laceration)  or  the  soft  brain 
may  be  compressed  within  its  unyielding  walls  by  a  depression  of  a 
part  of  the  walls  or  an  extravasation  of  blood  or  pus  within  them. 
In  contusion  of  the  brain  the  cortex  of  the  base  is  most  often  exposed 
to  injury,  but  as  the  posterior  two-thirds  of  the  base  are  well  pro- 
tected by  its  water  bed  of  cerebro-spinal  fluid  this  part  is  comparatively 
seldom  injured  while  the  frontal  lobes  are  often  injured. 

The  blood  supply  of  the  brain  is  most  abundant,  so  much  so  that 
the  carotid  may  be  ligated  without  effect  on  the  brain  though  cerebral 
complications  have  occasionally  followed  this  operation.  In  fact  both 
carotids  have  been  ligated  without  marked  cerebral  disturbance,  pro- 
vided an  interval  of  a  few  weeks  has  elapsed  between  the  two  opera- 
tions. After  ligature  of  one  or  both  carotids  or  in  case  of  other  dis- 
turbance of  the  cerebral  circulation  the  latter  is  e<][ualized  by  the 
anastomosing  circle  of  Willis.  The  effects  of  the  heart's  systole  on 
the  brain  are  diminished  by  the  tortuosities  of  the  arteries  (internal 
carotid  and  vertebral)  before  entering  the  cranial  cavity,  but  the  brain 
pukates  synchronously  with  the  systole  of  the  heart.  This  pulsation 
may  be  seen  or  felt  on  the  dura  unless  the  intra^'ranial  pressure  is 
increased,  when  the  pulsation  is  diminished  or  absent.  This  pulsation 
may  be  transmitted  to  the  overlying  soft  parts  where  the  bone  is 
wanting  on  account  of  injury,  disease  or  operation.  The  circulation 
in  the  smaller  cerebral  arteries  is  terminal,  i.  e.,  without  anastomosis, 
so  that  plugging  by  an  embolus  causes  blood  stasis  and  coagulation 
necrosis  in  a  cone-shaped  area  having  its  base  on  the  surface.  Wounds 
of  the  brain  from  injury  or  operative  incision  bleed  freely,  but  this 
bleeding  is  readily  checked.  The  brain  weighs  on  an  average  49|  oz. 
in  the  male  and  44  oz.  in  the  female. 

Localization  of  Cerebral  Functions. 

The  cortical  areas  whose  function  is  accurately  known  comprise  : 
(1)  The  7notor  area  ;  (2)  the  speech  areas ;  (3)  the  visual  areas  ;  (4) 
the  auditory  area;  (5)  the  area  of  the  sense  of  smell  and  taste.  The 
precise  limit  of  these  areas  is  not  accurately  known  and  one  area  may 
fuse  with  another.  It  is  most  important  to  know  the  position  of  these 
centers  as  a  guide  in  diagnosing  and  o])erating  on  lesions  of  the  cere- 
bral cortex  (Figs.  6  and  7). 

The  motor  area  comprises  the  cortex  of  the  anterior  and  posterior 
central  convolutions,  bordering  the  fissure  of  Rolando,  and  the  cortex 
immediately  adjacent  to  them,  especially  the  paracentral  lobule  on  the 
mesial  surface.  In  the  upper  third  of  the  Jiolandic  area  is  the  area  for 
the  lower  extremity,  in  the  middle  third  that  iov  tlu;  upper  extremity, 
and  in  the  lower  third  that  for  the  face  and  tongue  (facial  and  hypo- 
glossal nerves).     In  the  areas  for  both  extremities  the  centers  for  the 


THE  MOTOR   AREA. 


41 


proximal  portions  are  in  the  anterior  and  np])er  part  of  the  area  (/.  ^., 
in  the  anterior  eentral  convohition)  those  for  the  distal  portions  in  the 


Fk;.  (i. 
k 


Localization  of  fiinctiou  on  tlic  cereliral  cortex  ;  exteraal  snrface.     (After  Starr.) 

posterior  and  lower  part  of  the  area  and  tliose  for  tlie  intervening  por- 
tions in  the  space  between.     In  the  lower  third  of  tlie  motor  area  the 

Fig.  7. 
B 

PARACENTRAU 
LOBULE 


Localization  of  function  on  the  cerebral  cortex  ;  mesial  surface,     ^.\fter  KoriiKR.) 


centers  for  the  upper  facial  muscles  lie  above  and  in  front,  thnt  for  the 
platysma  above  and  behind  and  tliat  for  the  mouth  and  touijue  below. 


42  THE  HEAD  AND  NECK. 

The  movements  of  the  eyes  and  head  are  controlled  by  the  cortex  of 
the  posterior  part  of  the  second  frontal  convolution,  irritation  of  which 
causes  conjugate  movements  of  the  head  and  eyes  to  the  opposite  side. 

In  the  paracentral  lobule  from  before  backward  we  find  centers  for 
the  arm,  shoulder-girdle,  trunk,  pelvis,  leg  and  foot.  Here  the  centers 
for  both  extremities  so  merge  into  one  another  that  both  may  be  par- 
alyzed by  a  single  lesion. 

It  is  to  be  remembered  that  each  hemisphere  controls  movements 
mainly  on  the  opposite  side  of  the  body,  but  to  a  slight  extent  also  on 
the  same  side.  This  accounts  for  a  large  amount  of  the  recovery  after 
destruction  of  the  centers  of  one  side,  especially  those  of  the  distal 
movements  of  the  limbs.  This  recovery  is  explained  by  others  by  the 
fact  that  though  there  is  a  focus  for  the  movement  of  a  particular  part, 
like  the  thumb,  it  is  also  represented  with  diminished  intensity  over 
the  surrounding  cortex.  Hence  to  totally  paralyze  a  given  part  a 
considerable  amount  of  cortex  must  be  excised. 

The  speech  areas,  four  in  number  and  in  kind,  are  in  the  right  hemi- 
s])here  in  rigiit-luinded  persons  and  in  the  left  in  left-handed  persons. 
The  motor  speech  center  lies  in  the  posterior  part  of  the  third  fron- 
tal convolution  near  (just  in  front  of)  the  center  for  the  muscles  of 
speech  (hypoglossal  and  facial  nerves).  A  lesion  of  the  motor  speech 
center  causes  motor  apha.sia  in  which  there  is  loss  of  a  word-forming 
power  although  the  tongue  is  movable  and  consciousness  is  present. 

The  auditory  speech  center  is  in  the  posterior  two-thirds  of  the  first,  and 
perhaps  the  second,  temporal  convolution.  A  lesion  here  causes  '^icord- 
deafness,"  a  sensory  aphasia  in  which  the  memory  of  the  sounds  of  words 
is  lost  so  that  they  are  not  understood,  though  hearing  may  be  normal. 

The  visual  speech  center  lies  in  the  })osterior  part  of  the  angular 
convolution  of  the  lower  parietal  region.  Word-blindncas,  or  the  loss 
of  understanding  of  printed  or  written  language,  is  caused  by  a  lesion 
here,  though  sight  itself  is  normal.  The  power  of  writing  belongs  to 
speech  but  its  center  is  not  accurately  determined.  It  is  usually  lost 
when  the  motor  speech  area  is  destroyed,  but  some  cases  point  to  its 
probable  location  in  the  second  frontal  convolution,  others  to  its  location 
near  the  hand  center. 

The  visual  center  is  situated  in  the  occipital  lobe,  especially  in  the 
vicinity  of  the  calcarine  fissure.  Lesions  of  this  area  cause  a  half- 
blindness  of  both  eyes,  the  blind  field  of  vision  being  on  the  opposite 
side  to  the  lesion  and  on  the  same  side  of  the  body  in  both  eyes. 
Central  vision  is  unimpaired  and  the  pupils  react  normally. 

The  center  of  sensations  of  taste  and  smell  is  located  in  the  under  and 
inner  surfaces  of  tiie  tip  of  the  temporal  lobe  but  only  bilateral  lesions 
produce  noticeable  symptoms  for  each  lobe  is  related  to  both  sides  of 
these  sensory  organs.  The  same  may  be  said  of  the  center  of  sensations 
of  sound  which  is  located  in  the  first  and  second  tein]>()ral  convolutions. 

According  to  some  a  sensory  cortical  area  (faclile  and  inii.seular  fieiim- 
tions)  is  found  in  the  posterior  part  of  the  motor  area,  the  posterior 
central  convolution,  and  the  area  just  behind  this,  but  if  present  here 


CRAyiO-CEREBRAL   TOPOGRAPHY.  43 

this  area  is  not  coextensive  with  the  motor  area.  ^lotor  paralysis 
of  cortical  orifj'i  11  is  often  independent  of  anjcsthesia  and  wiien  the  latter 
coexists  it  may  be  due  to  a  dynamical  distiirijancc  and  is  usually  more 
temporary  than  the  motor  paralysis.  According  to  Fernierand  others, 
lesions  of  the  cortex  in  the  falciform  lobe,  esj^ccially  in  the  hipjwcampal 
region  and  the  gyrus  fornicatus  (Horsley),  cause  more  permanent 
ansesthesiie,  and  this  region  is  connected  by  association  fibers  with  the 
motor  area.  The  motor  and  sensory  tracts  are  separate  in  the  nerves, 
cord,  cms  and  internal  capsule  and  we  would  hardly  expect  them  to  be 
found  together  in  the  cortex. 

A  large  part  of  the  cortex  is  thus  seen  to  be  wanting  in  known 
function.  Of  this  portion  Flechsig  has  described  four  areas  in  the 
adult,  not  present  in  the  infant,  whose  structure  is  similar  and  differs 
from  that  of  other  parts.  These  areas  lie  in  the  frontal,  temporal  and 
posterior  jKirt  of  the  parietal  lobe  and  in  the  Island  of  Reil  and  are 
called  mental  or  a.'imciatioa  centers  because  they  join  together  the  activ- 
ities of  the  various  organs  of  sense.  These  and  other  unnamed  areas 
of  the  cortex  are  probably  related  to  the  higher  forms  of  intellectual 
activity,  for  the  full  play  of  which  a  general  integrity  of  the  whole 
brain  is  necessary.  But  a  disease  in  any  one  of  the  parts  does  not 
cause  the  loss  of  any  one  mental  faculty.  Thus  very  considerable 
damage  or  loss  of  substance  has  involved  the  frontal  lobes  without  a 
serious  disturbance  of  the  mental  powers. 

The  function  of  the  ('orpora  str'mta  and  optic  ihalami  is'undetermined. 
Lesions  of  them  cause  no  definite  symptoms  unless  they  involve  the 
tracts  in  the  internal  capsule.  The  crura  cerebri,  pons  and  medulla 
contain  the  centers  of  the  cranial  nerve  nuclei  and  transmit  the  motor 
and  sensory  tracts  to  the  cord.  Hence  lesions  in  them  cause  cranial 
nerve  palsies  on  the  same  side  and  motor  and  sensory  paralyses  of  the 
opposite  extremities.  Lesions  of  the  crura  involve  especially  the  third 
cranial  nerve,  those  of  the  pons,  the  fifth,  sixth  and  seventh. 

The  cerebellum  controls  the  equilibrium  of  the  body  so  that  a 
staggering  gait  and  vertigo  result  from  lesions  of  it,  especially  of  its 
median  lobe. 

The  medulla  contains,  in  addition  to  the  centers  named  above,  the 
respiratory  and  vaso-motor  centers  and  the  inhibitory  center  of  the 
heart,  also  the  reflex  centers  for  deglutition,  sneezing  and  coughing,  etc. 

Uj)on  the  above  local  symjitoms  we  are  dependent  for  our  diagnosis 
of  the  location  of  a  lesion.  In  order  to  be  able  to  expose  by  opera- 
tion that  part  of  the  brain  where  the  lesion  is  thus  located  we  must 
be  able  to  locate  certain  of  the  fissures  of  the  l)rain  on  the  surface  of 
the  heatl. 

Cranio- Cerebral  Topography. 

1.  TIte  Relation  of  the  lira  in  as  a  Whale  la  the~  Stnll. — The  lower 
limit  of  the  cerehruni  is  approximately  indieati'd  by  a  line  slightly 
convex  upward,  about  one  third  of  an  inch  al)(>ve  the  sujn'aorbital 
margin,  crossing  the   temi)()ral   crest    half  an   inch  above  the  external 


44 


THE  HEAD  AND  NECK. 


angular  process  of  the  frontal  bone,  thence  somewhat  convex  down- 
ward and  forward  to  just  above  (J  inch)  the  external  auditory  meatus 
and  from  here  to  the  external  occipital  protuberance,  just  above  the 
lateral  sinus  (see  p.  36).  Below  the  latter  part  of  the  line  lies  the 
cerebellum.  Each  cerebral  hemisphere  extends  up  to  the  superior 
longitudinal  sinus  (see  p.  36),  just  to  one  side  of  the  median  line. 

2.  As  to  the  fissures  the  localization  of  the  fissures  of  Rolando  and 
Sylvius,  and  perhaps  also  of  the  jmrieto-occipital  fissure,  enables  the  sur- 
geon to  expose  all  the  cortical  areas  whose  function  is  definitely  known. 

Fig.  8. 

BREGMA  F.   OF  ROLANDO 


PAR.  OCCIP. 
FISSURE 


Cranio-cerebral  topography,  showing  relation  of  brain  and  .sonip  of  the  fissures  and   convolutions  to 
thf  sutures  and  bony  landmarks. 


The  Fissure  of  Rolando. — Measure  in  the  median  line  the  dis- 
tance between  the  root  of  the  nose  (nasion)  and  the  external  occipital 
protuberance.  Half  an  inch  behind  the  center  of  this  line  (or  55/100 
of  the  distance  back  from  the  nasion)  represents  the  point  where  the 
continuation  of  this  fissure  meets  the  median  line.  From  this  point 
a  line  drawn  downwards  and  forwards  at  an  angle  of  67  degrees  with 
the  median  line  lies  over  the  fissure  of  Rolando.  This  is  about  3| 
inches  long  and  commences  half  an  inch  or  so  from  the  median  line. 
In  its  lower  third  the  fi.ssure  becomes  a  little  more  vertical  than  this 
line.  The  upper  end  of  the  fissure  of  Rolando  may  also  be  found  by 
drawing   Reid's  base  line   from  the   infraorbital  margin  through  the 


THE  FISSURE  OF  SYLVIUS. 


46 


center  of  the  external  auditory  meatus  and  erecting  a  perpendicular 
from  the  posterior  border  of  the  mastoid  process.  Where  the  latter 
line  reaches  the  median  line  gives  us  the  point  from  which  to  draw 
the  fissure  of  Rolando  as  before.  Or  it  may  be  drawn  from  this  point 
to  the  point  where  another  ]icrpendicular  to  the  base  line,  just  in  front 
of  the  external  auditory  meatus,  intersects  the  fissure  of  Sylvius  (Reid). 
This  intersection  lies  on  the  anterior  perpendicular  line  about  two 
inches  above  the  external  auditory  meatus.  According  to  Le  Fort  the 
direction  of  the  fissure  of  Rolando  is  also  represented  by  a  line  con- 
necting the  ujipermost  point  of  this  fissure,  as  determined  by  either  of 
the  preceding  methods,  with  the  middle  of  the  zygomatic  arch.  The 
lower  end  of  the  fissure  of  Rolando  is  about  half  an  inch  above  the 
fissure  of  Sylvius  and  one  inch  behind  the  junction  of  that  fissure  with 
its  vertical  limb.  The  lower  end  of  the  fissure  of  Rolando  is  about 
one  inch  (28  cm.),  the  upper  end  two  inches,  behind  the  coronal  suture. 
The  upper  end  is  about  at  the  center  of  the  sagittal  suture.  The  two 
central  convolutions  take  up  about  an  inch  on  each  side  of  the  fissure 
of  Rolando. 

Fir;.    9. 


MID.  POINT. 


EXT.  ANG. 
PROCESS. 


GLABELLAR. 


PAR.  OCCIP. 
FISSURE 


Cranio-cerebral  topography,  showing  the  relation  of  the  fissiiies  of  Rolando  and  Svlvius,  tlie  middle 
mpiiingeal  artery  and  the  latoral  sinus  to  tht'  Iniidniarks  and  sutures  of  tbe  head. 


The  fissure  of  Sylvius  is  represented  on  the  surface  by  a  line  from 
a  point  (pteriou)  1  ]  inches  horizontally  behind  the  external  angular 
process  to  a  point  ■[  of  an  inch  below  the  most  prominent  point  of  the 


46 


THE  HEAD  AND  NECK. 


parietal  eminence.  The  anterior  |  of  an  inch  of  this  line  represents 
the  main  fissure,  the  rest  of  the  line  the  horizontal  limb.  The  short 
vertical  limb  ascends  for  an  inch  just  behind  the  lower  end  of  the 
coronal  suture  from  the  junction  of  the  main  fissure  with  its  horizontal 
limb,  or  from  a  point  two  inches  horizontally  behind  the  external 
angular  process.  The  fissure  of  Sylvius  is  about  four  inches  long,  its 
anterior  part  is  just  above  (Horsley),  below  or  in  the  line  of  the 
squamous  suture.  Around  its  hind  end  lies  the  supramarginal  gyrus 
to  which  the  parietal  eminence  fairly  accurately  corresponds.  Below 
the  Sylvian  fissure  lies  the  first  temporal  gyrus.  The  anterior  part  of 
the  fissure  slants  gently,  the  posterior  part  more  sharply  upwards. 

Fig.  10. 

Superior  frontal  jis2v.re. 


End  of  cnUov)- 
marginal  fii>sut  e. 


Infei  lor  ftontal 
lobe 


Parieto- 
occipital 
fissure. 


w 


Fiasure  of 
Sylvius. 


Drawing  to  illustrate  crauio-cerebral  topography.     (Macalister.)    Taken  from  a  cast  prepared  by 

Professor  Cuuuinghani. 


The  parieto- occipital  fissure  lies  |  to  jV  of  an  inch  in  front  of  the 
lambda  (Horsley)  or  where  the  fissure  of  Sylvius  continued  would 
reach  the  median  line  (or  a  little  below  this).  It  separates  the  parietal 
and  occipital  lobes  and  runs  outwards  on  the  external  surface  of  the 
brain  for  about  an  inch. 


THE  EXTERNAL  AUDITORY  MEATUS.  47 

It  may  be  added  tliat  the  coronal  suture  lies  over  the  posterior 
extremities  of  the  three  frontal  gyr'i,  the  sulci  separating  which  may 
be  represented  as  follows:  the  .superior  by  a  line  drawn  backwarp 
from  the  supraorbital  notch  parallel  with  the  median  line,  the  inferior 
by  the  frontal  part  of  the  temporal  ridge. 

It  should  be  remembered  that  the  sulci  and  gyri  are  never  precisely 
alike  and  that  their  relations  to  the  surface  vary  slightly  in  different 
individuals,  but  as  we  expose  a  considerable  area  in  most  cases,  the 
desired  area  is  sure  to  be  exposed  and  can  be  recognized  by  its  relation 
to  the  sulci  and,  in  the  juotor  area,  by  electrical  stimulation. 

THE  EAR. 

The  pinna,  auricle  or  external  ear,  is  formed  by  a  partial  fusion 
of  six  small  tubercles  on  the  skin  at  the  end  of  the  first  visceral  cleft. 
In  connection  with  this  cleft  are  developed  the  Eustachian  tube, 
tympanum  and  external  meatus.  A  supplemental  rudimentary  pinna 
is  sometimes  formed  at  the  end  or  margins  of  one  of  the  lower  clefts, 
appearing  cougenitally  as  an  irregular  mass  of  fibro-cartilage  on  the 
side  of  the  neck.  AVlien  the  fusion  of  the  six  tubercles  is  less  com- 
plete than  usual,  a  tag-like  mpermuaerary  auricle  may  be  present  on 
the  cheek  just  in  front  of  the  ear,  or  fistulce  or  fissures  of  the  auricle 
may  occur.  The  more  marked  congenital  fistulse  may  be  due  to  de- 
fective closure  of  the  first  branchial  cleft.  A  dermoid  cyst  of  the 
pinna  may  result  if  the  opening  of  such  a  fistula  closes. 

The  framework  of  yello\v  elastic  cartilage  gives  the  ear  its  essential 
shape  which  varies  greatly  in  individuals  and  is  largely  influenced  by 
heredity.  A  hcematoma  may  occur  between  the  skin  and  the  cartilage 
of  the  ear  and  is  most  common  among  athletes,  such  as  football  players, 
boxers,  or  prize  fighters,  and  among  the  insane.  The  resulting  deposit 
and  contraction  of  new  connective  tissue,  especially  when  the  accident 
recurs  as  in  the  left  ear  of  prize  fighters,  causes  the  markings  of  the 
ear  to  be  obliterated  and  replaced  by  a  wrinkled  flattened  surface,  a 
condition  sometimes  known  as  prize  fighter\s  ear.  Curiously  enough 
a  fine  antique  bronze  statue  of  a  boxer  discovered  in  Rome  in  1885, 
and  some  other  antique  statues,  show  this  same  condition  of  the  left  ear. 

The  auricle  is  so  finnli/  attached  to  the  skull  by  the  cartilaginous 
meatus  that  the  body  of  average  weight  maybe  lifted  from  the  ground 
by  the  ears.  The  removal  of  the  pinna  is  followed  as  a  rule  by  com- 
paratively little  diminution  of  hearing.  As  there  is  but  little  subcu- 
taneous fatty  tissue  between  the  skin  and  the  cartilage  the  blood  cesi^els 
of  the  ear  are  not  well  protected  against  cold  so  that  the  ear  is  often 
the  seat  of  gangrene  from  frost  bite.  As  the  trunk  of  the  po.'<terior 
auricular  artery  occupies  the  angle  between  the  auricle  and  the  mas- 
toid process  we  carry  the  incision  to  expose  the  antrum  or  mastoid 
process  a  little  behind  this  angl<>. 

The  external  auditory  meatus  in  the  adult  is  about  1  inch  in  length, 
of  M'hich  ^  belongs  to   the  cartilaginous  and    I  to  the   bony  jwrtion. 


48 


THE  HEAD   AND   NECK. 


In  the  infant  the  bony  part  is  a  mere  ring  and  the  cartilaginous  por- 
tion is  relatively  longer  and  nearly  straight,  which  renders  an  exami- 
nation easier.  Owing  to  the  obliquity  of  the  drum  membrane  the 
inferior  and  anterior  walls  are  longer  than  the  superior  and  posterior 
respectively. 

Its  general  direction  is  inward  and  forward,  but  in  passing  from 
without  inward  the  outer  end  slopes  upward,  the  inner  part  downward 
so  that  the  center  of  the  canal  is  the  highest  point  of  an  upward  con- 
vexity. Furthermore  the  outer  part  inclines  sharply  forward  and 
then  bends  backward  while  the  bony  or  inner  portion  inclines  gently 
forward  again.  Hence  to  straighten  the  canal  to  introduce  a  speculum 
and  be  able  to  see  the  entire  membrane  the  pinna  is  pulled  upward  to 
straighten  the  upward  curve  and  backward  to  straighten  the  antero- 
posterior curves.  The  external  meatus,  the  promontory,  the  cochlea 
and  the  internal  meatus  lie  nearly  in  the  same  line. 

Fig.  11. 


_FENESTnA    OVALIS 
CLOSED    BY   STAPES 


Vertical  section  through  the  external  auditory  meatus  and  tynipannm,  passing  in  front  of  the  fenestra 
ovalis.     (Gkkrish,  after  Testut.) 


Diameters. — The  outer  end  is  elongated  vertically,  the  inner  end 
slightly  transversely,  while  the  middle  part  is  circular.  On  these 
differences  depend  the  two  forms  of  ear  specula,  the  one  round  which 
fits  the  narrow  circular  median  part  of  the  canal,  the  other  oval  which 
fits  and  fills  the  outer  part  of  the  canal.  The  latter  admits  more 
light  at  the  outer  end,  the  former  has  a  larger  lumen  where  it  reaches 
the  bony  portion.     The  osseous  part  is  narrower  than  the  cartilaginous 


FOREIGN  BODIES  IN  THE  EAR.  49 

and   tlie  narrotvest  part  of  the  canal   is  at  the  junction  of  the  middle 
and  inner  thirds. 

The  cartilaginous  portion  of  the  meatus  has  a  partial //•a//i.?Mwyt  of 
elastic  fihro-airtllafje,  continuous  with  the  pinna.  This  cartilage  forms 
hut  ^  of  the  circumference,  is  incomplete  above  and  behind  and  tails 
off  as  it  passes  inward  to  become  attached  to  the  lower  tiiird  of  the 
margin  of  the  osseous  meatus.  This  attachment  is  by  dense  fibro- 
elastic  tissue  wdiich  allows  of  the  shifting  of  position  of  the  pinna 
on  traction.  The  cartilage  presents  clefts  or  fissures  (f.ssures  of  San- 
torini)  on  the  floor  of  the  meatus,  which  are  filled  with  fii)rous  tissue. 
They  permit  of  easier  movement  of  the  cartilaginous  meatus  and  allow 
the  spread  of  inflammation  or  an  abscess  from  the  parotid  gland  below 
into  the  external  meatus  or  vice  versa. 

The  skin  lining  the  outer  part  of  the  cartilaginous  portion  is  sup- 
plied with  numerous  Iiairs,  which  help  to  keep  out  dust  and  insects, 
and  with  sebaceous  glands  which  may  be  the  starting  point  of  small, 
circumscribed  but  very  painful  abscesses.  The  ceruminous  or  wax 
glands,  resembling  modified  sweat  glands,  stud  the  skin  covering  the 
cartilaginous  meatus,  and  their  secretion,  "ear  wax,"  is  thought  to  be 
a  defense  against  dust  and  the  intrusion  of  insects.  When  this  wax 
is  secreted  excessively  it  may  produce  plugs  which  cover  the  drum 
membrane  or  block  the  meatus  and  so  produce  deafness  which,  curi- 
ously enough,  usually  comes  on  suddenly  and  is  continuous.  The  skin 
lining  the  osseous  portion  is  intimately  blended  with  the  periosteum 
and  contains  only  a  few  wax  glands.  The  skin  of  the  meatus  is  liable 
to  eczema  and  may  become  inflamed  (otitis  externa),  giving  rise  to  a 
profuse  muco-purulent  discharge.  In  addition  to  small,  circumscribed, 
glandular  abscesses  a  less  common  but  more  serious  and  more  diffuse 
form  may  occur  beneath  the  periosteum.  This  may  spread  out  onto 
the  surface  of  the  mastoid,  beneath  the  periosteum,  or  it  may  extend 
downward  into  the  parotid  rt^gion,  through  the  fissures  of  the  cartilage 
or  a  (jap  in  the  floor  of  the  osseous  portion.  This  gap  is  exj)lained  as 
follows.  The  osseous  ])ortion  is  largely  formed  by  the  outward  growth 
of  the  tympanic  ring,  at  first  in  two  lateral  tubercles  which  meet  in 
the  floor,  leaving  an  opening  mesial  to  their  junction,  which  may  some- 
times ])ersist.  J*<>li/j'i  may  grow  from  the  soft  linings  of  the  canal  and 
exostoses  from  its  bony  walls. 

Foreign  bodies  are  often  lodged  in  the  meatus  and  inav  be  very 
difficult  of  extraction.  More  damage  has  Ix'en  done  in  manv  cases  by 
blind  or  forcible!  attempts  to  remove  the  foreign  body  than  bv  leaving 
it  in  place.  The  ear  drum  and  tym|)anum  have  been  injured  in  such 
attempts  at  removal,  while  on  the  other  hand,  eases  are  reported  where 
foreign  bodies  have  remained  in  the  ear  from  thirty  to  sixty  years 
without  harm.  The  extraction  should  only  be  attempted  bv  means 
of  approjiriate  forceps  or  a  blunt  hook,  while  the  body  is  seen  and  the 
instruments  guided  to  it  through  a  sjieculum  ;  or  by  means  of  a  stream 
of  tepid  Nvater  forcibly  injected  through  the  narrow  nozzle  of  a  svringe 
so  as  to  get  behind  the  body  and  force  it  out. 
4 


50  THE  HEAD   AND  NECK. 

The  relations  of  the  external  auditory  meatus,  especially  its  bony 
portion,  are  of  practical  importance.  The  superior  wall  is  in  relation 
with  the  middle  fossa  of  the  skidl  and  is  separated  from  it  by  a  bony 
plate  4-5  mm.  thick,  and  sometimes  thinner.  Hence  long-continued 
subperiosteal  inflammation  or  bone  disease  in  the  meatus  may  extend  to 
the  meninges  or  the  brain,  without  necessarily  first  involving  the  tym- 
panum. Posteriorly  the  meatus  is  in  relation  with  the  mastoid  j^rocess 
and,  at  its  inner  end,  with  the  mastoid  antrum.  From  the  latter  the 
meatus  is  separated  by  a  thin  plate  of  bone,  sometimes  defective,  so 
that  inflammations  of  the  one  may  extend  to  the  other  and  inflamma- 
tion in  the  antrum  may  often  cause  a  swelling  or  bulging  of  the  pos- 
tero-superior  aspect  of  the  inner  end  of  the  meatus.  The  inferior  wall 
is  in  relation  with  the  portion  of  the  parotid  gland  occupying  the  back 
of  the  glenoid  fossa  and,  as  stated  above,  a  congenital  gap  may  occur 
here  which  permits  the  ready  extension  of  inflammation  from  the  one 
to  the  other.  The  anterior  wall  is  in  relation  to  the  temporo-maxillary 
joint  and  may  be  fractured  l)y  the  condyle  of  the  jaw  in  falls  upon  the 
chin.  As  a  result  of  this  injury  there  may  be  considerable  bleeding  from 
the  ear,  as  also  in  case  the  drum  membrane  is  ruptured,  hence  this  symp- 
tom does  not  necessarily  indicate  fracture  of  the  base  of  the  skull.  The 
proximity  of  this  part  to  the  joint  helps  to  explain  the  pain  of  move- 
ment of  the  jaw  when  the  meatus  is  inflamed,  but  this  is  also  explained 
by  the  two  parts  being  supplied  by  the  same  nerve  (auriculo-temporal). 

Nerve  Supply. — The  anrieuIo-temporaIsup\)\ies.  parts  of  the  meatus 
and  the  outer  surface  of  the  pinna.  The  f/reat  auricular  and  small 
occipital  also  supply  the  pinna,  while  Arnold's  nerve  supplies  the  back 
of  the  concha  and  the  lower  and  back  part  of  the  outer  portion,  of  the 
canal.  Arnold's  nerve,  a  small  branch  of  the  vagus,  has  been  nick- 
named "  alderman\s  nerve  "  from  the  following  circumstance  :  It  is  said 
that  diners  after  a  heavy  dinner  were  wont  to  touch  the  back  of  the  ear 
with  a  napkin  moistened  with  rose  water.  This  is  said  to  be  very  re- 
freshing by  reason  of  the  stimulation  of  Arnold's  nerve  and  thereby, 
reflexly,  of  the  main  branch  of  the  vagus,  which  supplies  the  stomach. 

The  irritation  of  the  meatus  by  a  plug  of  wax,  the  introduction  of  a 
speculum,  the  presence  of  a  foreign  body  or  of  an  inflammation  may  give 
rise  to  symptoms  which  are  explained  as  reflexes.  Thus  ear-coughing 
and  ear-sneezing  arc  reflexes,  through  Arnold's  nerve,  of  the  branches 
of  the  vague  supplying  the  lungs.  Vomiting  has  been  caused  in  like  man- 
ner by  an  irritation  through  Arnold's  nerve  of  the  gastric  branches  of 
the  vagus.  In  ear-yaivning  the  irritation  is  conveyed  through  the  auric- 
ulo-temporal nerve  to  other  branches  of  the  fifth  nerve  which  supply  the 
muscles  of  the  jaw.  Again,  other  branches  of  the  same  division  of  the 
fifth  nerve  sujiply  the  lower  teeth  (inferior  dental)  and  the  tongue  (gus- 
tatory); a  circumstance  that  may  account  for  the  frequent  association  of 
earache  with  toofJiarhe  or  disease  in  the  anterior  two-thirds  of  the  tongue. 

The  tympanic  membrane  is  placed  so  as  to  face  obliquely  outward, 
downward  and  slightly  forward.  The  obliquity  with  the  horizontal 
plane  is  30°-50°  at  birth  and  40°-45°   in  the  adult.     According  to 


THE   TYMPAXIC  MEMBRA  XE.  51 

Fick  the  more  vertical  the  membrane  the  more  sensitive  is  it  to  sound 
and  it  has  been  observed  to  be  less  oblique  in  musicians  than  in  those 
lacking;  in  a  taste  for  music.  Owing  to  the  inclination  of  the  mem- 
brane and  the  sloping  downward  of  the  inner  end  of  the  canal  an  acute- 
angled  sinus  is  formed  between  the  two  where  small  foreign  bodies, 
pus  and  other  fluids  are  likely  to  collect.  The  membrane  is  nearly 
circular  but  slightly  longer  vertically  (10  mm.)  than  horizontally  (9 
mm.).  Its  shape  however  is  somewhat  irregular  for  above  and  an- 
teriorly, where  the  tympanic  ring  is  interrupted  by  a  slight  recess,  the 
notch  of  Rivini,  the  membrane  extends  to  the  margin  of  the  tympanum. 
This  portion  of  the  membrane,  limited  below  by  two  small  fibrous 
bands  connectiuy;  the  two  ang^les  or  corners  of  the  notch  of  Rivini 
with  the  sh(jrt  process  of  the  malleus,  bulges  outward  instead  of  in- 
ward and  is  thin  and  lax,  hence  called  by  Shrapnell  memhrana  fiaccida, 
and  is  known  as  ShrapnelC s  membrane.  This  from  its  thinness  may 
be  readily  ruptured  by  a  blow  and  through  it  pus  may  escape  from  the 
middle  ear  without  perforating  the  membrane  proper. 

The  inward  bulging  of  the  tympanic  membrane  is  due  to  the  position 
of  the  long  process  or  handle  of  the  malleus  which  is  embedded  between 
the  circular  and  radiating  fibers  of  the  membrane.  The  center  or 
umbo  of  this  depression  is  slightly  below  the  center  of  the  membrane 
and,  as  may  be  seen  from  either  side,  corresponds  to  the  slightly  flat- 
tened end  of  the  handle  of  the  malleus.  A  section  of  the  membrane 
below  the  umbo  shows  this  part  to  be  slightly  convex  externally. 
When  pathological  products  such  as  mucus,  pus,  etc.,  are  pent  up  in 
the  tympanum  the  inward  bulging  is  diminished  or  even  replaced  by 
an  outward  one.  On  the  other  hand,  when  the  Eustachian  tube  is 
occluded  and  no  air  can  reach  the  tympanum  the  atmospheric  pressure 
on  the  outside  of  the  memljrane  increases  the  inward  V)ulging  to  such 
an  extent  that  the  stapes  is  constantly  pressed  inwards  and  a  ringing 
in  the  ear  is  produced. 

Fig.   ]2. 

POS.    FOLD 

LONG  PROCESS  OF  ■Nr.u^|   br  ^  N  c'^ '|SH  O  RT  PROCESS 

kLLEUS 

SHRAPNELL'S    MEMBRANE 
ANT.     FOLD    OF    MEMBRANE 


PROMONTORY — ^ 


LIGHT    CONE 


Otoscopic  image  of  right  ear  dniiu.     (  Tkbti-t.  ) 


The  otoscopic  image  of  the  membrane  as  seen  through  an  ear  speculum 
is  that  of  a  round  or  oval,  concave  surface,  pearl  gray  in   color  with 


52  THE  HEAD  AND  NECK. 

sometimes  a  violet  or  yellowish  brown  tinge  and  with  the  following 
markings.  Extending  from  a  little  in  front  of  the  upper  pole  down- 
ward and  a  little  backward  to  the  umbo  is  seen  the  handle  of  the  malleus. 
At  the  upper  end  of  this,  and  near  the  circumference  of  the  membrane, 
is  a  whitish  point,  the  short  process  of  the  malleus.  Behind  and  parallel 
Avith  the  handle  of  the  malleus,  but  less  distinct  and  not  as  long,  is 
seen  the  long  process  of  the  incus.  Extending  downward  and  forward 
from  the  umbo  is  the  ''light  cone/'  a  whitish  cone-shaped  area  of  vary- 
ing shape  and  size  where  the  light  thrown  in  is  reflected  back,  owing 
to  the  inclination  and  curvature  of  the  membrane.  Pathologically 
this  light  cone  may  be  wanting  when  a  perforation  occupies  its  posi- 
tion, when  it  is  bulged  outward  or  the  surface  dulled  by  an  inflamma- 
tion of  the  membrane.  Sometimes  the  chorda  ti^mpani  nerve  may  be 
seen  crossing  transversely  near  the  upper  end  of  the  handle  of  the 
malleus.     The  promontory  may  also  be  seen  behind  the  umbo. 

Practically  we  may  divide  the  membrane  into  the  parts  above  and 
below  the  umbo.  The  section  above  the  umbo  corresponds  to  the 
ossicles,  their  muscles  and  ligaments,  the  chorda  tympani,  the  foramen 
ovale  and  the  promontory.  The  greatest  vascularity  is  in  this  part, 
the  blood  vessels  being  especially  prominent  on  each  side  of  the  handle 
of  the  malleus.  The  section  of  the  membrane  below  the  umbo  corre- 
sponds to  no  important  parts  and  is  less  vascular  and  less  sensitive 
than  the  upper  segment ;  hence  paracentesis  is  usually  practiced  here 
and  for  the  additional  reason  that  the  lower  incision  affords  the  better 
drainage  of  the  tympanum.  It  is  noticeable  however  that  the  floor 
of  the  tympanum  is  at  a  lower  level  than  the  lower  end  of  the  mem- 
brane so  that  perfect  drainage  cannot  be  secured  in  the  upright  posi- 
tion. As  the  membrane  consists  of  a  framework  of  circular  and  radiat- 
ing fibers  of  connective  tissue,  covered  internally  by  mucous  membrane 
and  externally  by  epidermis,  it  possesses  little  elasticity  ;  hence  incisions 
do  not  gape  much  and  heal  readily,  often  before  it  is  desired,  so  that 
paracentesis  may  need  to  be  repeated.  In  case  of  spontaneous  perfora- 
tion from  ulceration  the  wider  opening  resulting  may  heal  slowly  and 
sometimes  not  at  all.  But  an  opening  in  the  membrane  does  not 
necessarily  produce  much  deafness. 

The  arteries  supplying  the  membrane  are  derived  from  the  stylo- 
mastoid and  the  tym|)anic  branch  of  the  internal  maxillary,  the  latter 
supplying  mostly  the  part  below  the  umbo,  the  former  that  above  it. 
The  aiiri('ulo-f('nipor((l  nerve  supplies  the  membrane. 

The  tympanum  or  middle  ear  is  a  narrow  cleft-like  cavity  inter- 
vening between  tlie  external  meatus  and  the  internal  ear.  It  is  sepa- 
rated from  the  former  by  the  ear  drum,  the  vibrations  of  which  are 
transmitted  to  the  internal  ear  by  a  chain  of  three  ossicles  which  cross 
this  narrow  s])ace.  It  contains  air  which  reaches  it  from  the  pharynx 
through  the  Eustachian  tube  and  it  connects  })osteri<)rly  with  the  mas- 
toid antrum  and  cells.  Its  mucosa  is  ciliated  except  where  it  covers 
the  membrane,  the  ossicles  and  the  promontory,  where  it  is  thin  and 
squamous.     It  measures  15  mm.  in  height  and  length,  above  it  is  5-6 


THE    JVMI'AXU.V  OR   MIDDLE  EAR.  53 

mm.  broad,  below  4  ram,,  and  the  umbo  and  promontory  are  only 
separated  by  1-2  mm.  It  projects  above  the  upper  limit  of  the 
membrane  where  it  widens  out  somewhat  and  is  called  the  tympanic 
attic.  The  cavity  lies  o/jliijueli/  so  that  its  outer  and  inner  walls  look 
outward,  downward  and  forward. 

On  its  inner  wall,  opposite  the  umbo,  is  the  promontort/,  above  this 
the  fenestra  ovalis  and  below  and  behind  the  latter  the  fenestra  ro- 
tuitda.  The  fenestra  ovalis  leads  into  the  vestibule  and  is  closed  dur- 
ing life  by  the  stapes.  In  the  angle  between  the  roof  and  the  inner 
wall,  and  appearing  as  a  sligiit  convexity  above  the  fenestra  ovalis,  is 
the  facial  canal  (aqueductus  Fallopii)  transmitting  the  facial  nerve. 
The  wall  of  this  canal  is  very  thin,  especially  in  infants  in  whom  it 
may  be  defective.  This  fact  accounts  i'ov  facial  paralysis  in  the  course 
of  chronic  otitis  media,  especially  in  children. 

The  floor  of  the  tympanum  is  like  a  narrow  gutter  below  the  level 
of  the  ear  drum  and  hence  drainage  of  the  tympanum  is  not  perfect 
after  paracentesis  of  this  membrane.  The  floor  is  only  separated  from 
the  jitf/alar  and  carotid  fossre  by  a  thin  plate  of  bone  and  fatal  hemor- 
rhage from  the  carotid  has  followed  necrosis  of  this  bony  plate. 

The  outer  wall  consists  chiefly  of  the  membrane,  but  is  partly  osseous 
and  presents  the  apertures  of  entrance  and  exit  of  the  chorda  tyrnpani 
nerve  which  lies  beneath  the  mucous  membrane  of  this  wall.  This 
nerve  crosses  the  upper  part  of  the  membrane  internal  to  the  handle 
of  the  malleus.  If  affected  in  connection  with  otitis  media  its  irrita- 
tion causes  prickling  of  the  end  of  the  tongue,  its  destuction  unilateral 
loss  of  taste  in  the  anterior  two-thirds  of  the  tongue. 

The  roof  or  tegmen  tympani  is  a  very  thin  layer  of  bone  which 
separates  the  tympanum  from  the  middle  fossa  of  the  skull.  Defects  are 
sometimes  found  in  the  tegmen  so  that  in  cases  of  otitis  media  inflam- 
mation may  spread  from  the  ear  to  the  meninges  or  the  brain  by  ex- 
tension directly  through  such  defects  or  after  necrosis  of  the  thin  bony 
plate,  or  indirectly  along  small  veins  passing  through  the  tegmen  to 
the  sigmoid  and  superior  petrosal  sinuses. 

The  petro-squamous  suture  forms  the  outer  boundary  of  the  tegmen, 
the  emincntia  arcuata  over  the  su))erior  semicircular  canal  and  the 
groove  leading  to  the  hiatus  Fallopii  form  the  inner  boundary.  The 
suture  is  generally  obliterated  by  the  end  of  the  twelfth  year,  before 
which  time  inflammation  may  readily  spread  through  the  suture  mem- 
brane from  the  tympanum  to  the  meninges.  The  suture  not  infre- 
quently remains  open  longer.  Fracture  of  the  tegmen  and  rupture  of 
its  closely  adhering  meml)ranes  causes  an  escape  of  cerebro-spinal  fluid 
into  the  middle  ear.  The  tegmen  is  continuous  with  the  roof  of  the 
antrum  behind  and  slopes  downward  in  front  to  become  continuous 
with  the  roof  of  the  Kustaciiian  canal. 

The  posterior  wall  at  its  upper  end,  on  a  level  with  the  tympanic 
attic,  presents  the  irregularly  triangular  opening  into  the  antrum,  and 
below  this  there  are  sometimes  smaller  openings  directly  into  the 
mastoid  cells. 


54  THE  HEAD  AXD  XECK. 

As  the  result  of  chronic  inflammatory  changes  i\\e  joints  of  the  ossicles 
may  become  stiffened  so  that  they  do  not  readily  transmit  slight  vibra- 
tions. It  is  in  such  cases  of  partial  deafness  that  the  hearing  is  better 
in  a  noisy  place,  like  a  crowded  street  or  a  railway  train,  for  the  result- 
ing vibrations  are  sufficient  to  set  the  ossicles  in  vibration  and  the 
additional  vibrations,  due  to  the  voice,  are  more  readily  transmitted  to 
the  internal  ear.  When  the  malleus  and  incus  are  removed  and  the 
membrane  is  freely  perforated  a  considerable  degree  of  hearing  may 
be  retained,  the  vibrations  being  transmitted  directly  to  the  stapes 
through  the  aperture  in  the  membrane.  The  tympanum  communicates 
with  surrounding  parts  by  many  apertures,  both  large  and  small, 
through  which  pathological  processes  may  extend  in  various  directions. 

The  mastoid  antrum,  variable  in  size  but  about  as  large  as  a  pea, 
lies  behind  the  attic  of  the  tympanum  into  which  it  opens.  The  pas- 
sageway is  frequently  on  a  higher  level  than  the  floor  of  the  antrum, 
so  that  drainage  into  the  tympanum  from  the  antrum  is  not  well  pro- 
vided for  and  fluid  is  apt  to  gravitate  into  the  mastoid  cells  which 
communicate  with  it.  As  the  facial  canal  descends  on  the  inner 
wall  of  this  passageway  one  must  keep  to  the  outer  wall  of  the  passage 
in  operations,  in  order  to  avoid  the  nerve.  It  follows  also  that  the 
antrum  lies  behind  the  facial  nerve. 

The  antrum  lies  nearer  the  outer  surface  of  the  skull  than  the  tym- 
panum and  is  covered  externally  by  the  descending  plate  of  the  squamous 
bone,  between  the  temporal  ridge  and  the  masto-squamous  suture.  This 
plate  may  present  defects  at  birth,  exposing  the  antrum.  The  masto- 
squamous  suture,  which  is  wide  in  infancy,  persists  frequently  till 
puberty,  occasionally  through  life,  and  traces  of  it  are  also  found  in  the 
adult  in  the  shape  of  foramina,  etc.,  through  some  of  which  minute 
veins  pass  from  the  antrum  and  tympanum.  Inflammation  travelling 
along  these  veins  may  set  up  a  periostitis  on  the  mastoid.  As  long  as 
this  suture  remains  uuossified  inflammation  may  spread  and  pus  find  a 
free  outlet  to  the  surface  from  the  tympanum  and  antrum,  an  occur- 
rence not  infrequent  in  children. 

Operations  confined  to  this  plate  of  the  squamosal,  i.  e.,  above  the 
masto-squamous  suture,  are  safe  as  regards  injury  to  the  sigmoid  sinus 
or  the  facial  canal.  Roughly  speaking  the  level  of  the  antrum  corre- 
sponds to  that  of  the  upper  half  of  the  external  osseous  meatus  and  the 
passage  between  the  tympanum  and  the  antrum  corresponds  to  the 
postero-superior  quadrant  of  the  meatus.  Hence  the  operation  of 
opening  the  antrum  is  commenced  in  the  bone  just  behind  this  quad- 
rant, where  Macewen  has  pointed  out  the  existence  of  what  he  calls 
the  suprameatal  triangle.  This  occurs  in  99.5  per  cent,  and  is  well 
marked  in  94.G  per  cent,  of  cases.  It  is  usually  a  depressed  area, 
sometimes  a  slightly  prominent  one.  It  is  bounded  above  by  the  pos- 
terior root  of  the  zygoma,  below  by  the  postero-superior  quadrant  of 
the  external  meatus  and  behind  by  a  line  drawn  vertically  from  the 
posterior  border  of  the  meatus.  The  opening  is  to  be  made  at  the 
latter  line,  the  base  of  the  triangle,  and  is  to  be  carried  inward,  with  a 


THE  MASTOID  .\^rnf\^f. 


55 


slight  inclination  forward,  parallel  with  the  hony  external  auditory 
canal,  the  direction  of  which  may  be  determined  by  a  probe  passed 
into  it  i)Osteriorly  between  the  skin  and  the  l)ony  wall.  At  this  point 
of  entrance  the  outer  wall  of  the  antrum  is  aiiout  2  mm.  tliici:  in  the 
infant,  1  cm.  at  nine  years  (Symington)  and  1^  cm.  (|  inch)  or  less 
in  the  adult,  while  the  inner  wall  averages  f  of  an  inch  from  the  sur- 
face in  tiie  adult.  Hence  in  infants  pus  in  the  antrum  can  readily 
reach  the  surface  or  be  readily  evacuated  by  operation.  As  the  in- 
crease of  growth  of  the  mastoid  involves  principally  the  outer  part  the 
antrum  becomes  more  and  more  deeply  placed. 


Fk;.   13. 


etAPO" 


INTERNAL      INTERNAL 

JUGULAR        CAROTID 

VEIN  ARTERY 


AQUEDUCT    OF    FALLOPIUS 


Coronal  section  of  the  right  temporal  boue,  passing  through  the  Kiistaehian  tube  and  the  uiidille 
of  the  tympanum.  Both  surfaces  of  the  section  are  shown,  the  parts  being  hinged  on  the  line  zz. 
(Gerrish  after  Tkstut.) 

The  other  relations  of  the  antrum  are  of  great  importance  iu  case  of 
inflammation  extending  int(»  this  cavity  or  of  operations  to  evacuate 
the  pus.  Such  inflammations  readily  extend  into  the  antrum  from  the 
tympanum  on  acconnt  of  the  free  opening  between  them  and  the  con- 
tinuity of  their  lining  mucosa.  The  nuiro.sa  of  tiie  antrum  is  thin  and 
not  ciliated.  Tiie  roof  or  tegmcn  antri  is  a  very  (liin  plate  (about  1 
mm.)  of  bone  continuous  with  but  at  a  little  higher  level  than  the  tcgmen 
tympani.  Inflammation  may  readily  extend  through  this  thin  roof  to 
the  meninges,  causing  meningitis,  or  into  the  neighboring  brain,  caus- 
ing an  al)scess  of  the  temjxtro-sphenoidal  lobe  or  of  the  cerebellum. 
The  lower  border  of  the  posterior  root  of  the  zygoma  indicates  the 
level  of  the  roof  of   the  antrum  and  a  few  lines  above  this  is  the  base 


56  THE  HEAD  A^D  XECK. 

of  the  brain.  That  part  of  the  anterior  antral  wall  separating  the 
antrum  from  the  inner  end  of  the  external  auditory  canal  is  thin  and 
sometimes  defective  so  that  pus  from  the  antrum  has  been  known  to 
escape  directly  into  the  meatus  and  inflammation  of  the  antrum  may 
be  shown  by  a  bulging  of  the  postero-superior  aspect  of  this  part  of 
the  canal.  Postero-internally  the  antrum  is  in  close  relation  with  the 
sigmoid  sinus,  5-7  mm.  intervening  in  the  infant.  The  rear  of  the 
antrum  may  be  freely  and  safely  exposed  as  far  as  its  outer  covering 
by  the  descending  plate  of  the  squamous  extends. 

Development. — The  antrum  is  present  and  nearly  of  full  size  at  birth 
while  the  mastoid  cells  are  developed  later.  The  mastoid  process  is 
present  at  birth  but  does  not  become  pronounced  externally  until 
about  the  second  year  and  it  continues  to  grow  for  many  years.  The 
mastoid  celts  are  developed  with  the  process  but  at  first  are  like  spaces 
of  cancellous  bone;  the  true  air  cells  do  not  appear  until  after  puberty. 
The  cells  of  the  mastoid  continue  to  enlarge  and  extend  well  into 
adult  life,  when  they  may  reach  superiorly  within  half  an  inch  of  the 
squamo-parietal  suture,  anteriorly  over  the  external  meatus,  posteriorly 
to  the  masto-occipital  suture,  and  rarely  beyond  it. 

The  antrum  is  surrounded  by  mastoid  cells  on  all  sides  but  its  roof. 
Most  of  the  mastoid  cells  open  directly  or  indirectly  into  the  antrum 
and  are  lined  by  a  mucosa  continuous  witii  and  similar  to  that  of  the 
antrum,  hence  in  inflammation  of  the  latter  the  former  are  secondarily 
involved.  Suppurative  inflammation  of  the  mastoid  antrum  and  cells 
is  one  of  the  most  important  complications  of  middle  ear  disease. 
Some  of  the  more  distant  inferior  cells  are  diploic  spaces  filled  with 
red  marrow,  and  have  no  direct  connection  with  those  above,  but  in 
case  of  inflammation  the  thin  septa  between  may  become  disintegrated.' 
InternaUy  the  mastoid  cells  come  in  very  close  relation  to  the  sigmoid 
groove.  Onlv  a  thin  osseous  layer  separates  them  and  occasionally 
this  is  defective.  As  this  layer  is  perforated,  opposite  the  sigmoid 
bend,  by  minute  veins  leading  from  the  mastoid  antrum  and  cells  to 
the  sigmoid  sinus  thrombosis  of  the  latter  may  result  from  inflamma- 
tion in  the  former.  In  cases  where  the  outer  surface  of  the  mastoid 
is  perforated,  as  the  result  of  a  fracture,  or  a  congenital,  atrophic,  or 
pathological  loss  of  substance,  emphysema  may  occur  and  form  a 
tumor-like  bulging  [pneumatocele)  over  the  mastoid,  the  air  coming 
from  the  mastoid  cells. 

The  Eustachian  tube,  connecting  the  tympanum  with  the  naso- 
pharynx, measures  1|  inches  in  length  in  the  adult,  and  half  of  this 
in  the  infant,  in  whom  it  is  also  wider.  Its  direction  is  forward  with 
an  inclination  of  45°  inward  and  40"  downward  in  the  adult,  while 
in  the  infant  its  downward  inclination  is  only  10°.  These  facts  ex- 
plain tlie  readiness  with  which  inflammation  spreads  from  the  pharynx 
to  the  middle  ear  and  pus  or  injected  fluid  in  the  middle  ear  escapes 

'  According  to  ZiickerkanfU  the  mastoid  cells  are  entirely  air  cells  in  36.8  per  cent., 
entirely  diploic  in  20  per  cent.,  and  partly  air  partly  diploic  cells  in  42.2  per  cent,  of 
all  cases. 


THE  KUSTACHIAN  TUBE.  57 

into  the  pharynx.  As  the  tube  is  shorter,  wider  and  more  liorizontal 
in  iiif(int>i  and  young  chihlren  inlhitnination  spreads  more  easily  from 
the  piiarynx  to  the  tympanum  in  young  sul)jects.  Tiie  tipapan'w  orifice 
of  the  tube  is  on  a  level  with  the  roof  and  inner  wall  of  the  tympanum 
and,  as  it  is  on  a  higher  level  than  the  floor,  it  does  not  serve  well  for 
drainage,  A  straight  instrument  passed  through  the  tube  and  on 
through  the  tympanum  would  strike  the  jf)int  between  the  ineus  and 
stapes  and  pass  into  the  antrum. 

In  the  adult  the  posterior  onc-foiirlh  of"  tube  is  l>oi\>i,  the  rest  is 
cartilaginous,  the  point  of  junetion,  in  the  petro-squamous  angle, 
being  the  narrowest  part  of  the  tube.  At  the  same  point  the  tube 
bends  slightly,  though  for  practical  purposes  it  may  be  regarded  as 
straight.  In  the  middle  of  its  course  it  lies  close  to  and  parallel  with 
the  carotid  artery,  which  is  internal  to  it.  The  lumen  of  the  bony 
portion  is  always  open,  that  of  the  cartilaginous  part  is  merely  poten- 
tial and  is  only  open  during  the  act  of  swallowing  when  air  may  pass 
from  the  pharynx  to  the  tympanum  and  equalize  the  atmospheric  pres- 
sure on  the  two  sides  of  the  membrane.  When  the  tube  is  obstructed, 
as  by  inflammation  or  a  thickening  of  the  mucosa  or  by  pressure  upon 
its  pharyngeal  orifice,  the  pressure  on  the  outside  of  the  membrane  is 
in  excess,  so  that  the  latter  is  thrust  inward  and  presses  the  stapes 
against  the  fluid  of  the  vestibule  which  causes  an  annoying  buzzing 
or  singing.  If  the  obstruction  is  but  slight  the  singing  may  cease 
after  an  act  of  swallowing,  or,  failing  in  this,  by  a  forcible  expiration 
while  the  nose  and  mouth  are  kept  closed  ( Valsalva's  method)  or  by 
forcibly  inflating  the  nose  and  naso-pharynx  by  a  rubber  bag  whose 
outlet  is  held  in  one  nostril  while  the  patient  swallows  a  mouthful  of 
water  as  the  bag  is  compressed  {Politzer's  method)  or,  finally,  by  infla- 
tion through  a  Eustachian  catheter  passed  into  the  pharyngeal  orifice 
of  the  tube. 

These  jihenomena  are  readily  explained  by  the  awttomicrd  structure 
of  the  cartilaginous  part  of  the  tube  which  is  made  of  a  plate  of  car- 
tilage folded  on  itself,  the  two  borders  of  which  are  joineil  l)v  fibrous 
tissue  on  the  outer  aspect  of  the  tube  to  complete  the  lumen.  To  this 
fibrous  portion  are  attached  the  tensor  palati  and  palato-pharyngeus, 
so  that  when  they  act  in  raising  the  ])alate  or  in  deglutition  the  tube 
is  o])ened  by  their  pulling  the  fibrous  portion  away  from  the  cartilag- 
inous portion.  80  in  swallowing  or  any  act  involving  the  elevation 
of  the  palate  the  Eustachian  tube  is  opened.  Advantage  is  taken 
of  this  by  artillerymen,  who  hold  open  and  breathe  through  the  mouth 
when  a  loud  report  is  expected.  When  we  breathe  through  the  open 
mouth  the  palate  is  kept  elevated  and  eonse([uently  the  Kustaehian 
tube  is  kept  open  so  that  the  vibrations  of  the  air  on  the  membrane 
may  be  equalized  by  reaching  it  from  both  sides.  Thus  not  only  the 
painful  shock  of  the  loud  report  is  avoided,  but  even  the  danger  of 
rupturing  the  membrane. 

The  trumpet-shaped  pharyngeal  orifice,  the  largest  part  of  the  tube, 
is  vertically  elongated  and  is  marked  by  a  prominent  ridge  above,  in 


58  THE  HEAD  AXD   NECK. 

front  and  behind.  Its  position  is  about  at  the  center  of  the  lateral 
aspect  of  the  naso-phari/iur,  its  upper  border  being  about  equidistant 
and  half  an  inch  from  the  roof  of  the  pharynx  above,  its  back  wall 
behind,  the  level  of  the  palate  below  and  the  end  of  the  inferior  tur- 
binate bone  in  front  (Tillaux).  It  lies  nearly  directly  above  the  pos- 
terior margin  of  the  aponeurosis  of  the  soft  palate  and  looks  downward, 
inward  and  forward.     At  birth  it  is  at  or  below  the  level  of  the  palate. 

With  a  knowledge  of  its  position,  and  remembering  that  it  is  bounded 
above  and  at  the  sides  by  a  projecting  cartilaginous  rim  and  is  open 
below,  we  pass  a  Eustachian  catheter  in  one  of  several  ways  :  (1) 
After  passing  it  through  the  inferior  meatus  of  the  nose  with  its  beak 
downward  until  it  touches  the  posterior  wall  of  the  naso-pharynx  the 
beak  is  turned  outward  and  the  catheter  is  slowly  withdrawn  until  it 
is  felt  to  glide  over  the  projecting  posterior  rim  of  the  opening  when 
it  is  turned  still  farther  until  the  beak,  and  the  ring  on  the  handle, 
point  to  the  outer  cauthus  of  the  eye.  (2)  After  reaching  the  posterior 
wall  of  the  naso-pharynx  the  beak  is  turned  inward  and  the  catheter 
withdrawn  until  its  beak  catches  on  the  posterior  border  of  the  nasal 
septum  when  the  catheter  is  rotated  through  a  semicircle  so  that  the 
beak  gliding  over  the  upper  surface  of  the  soft  palate  enters  the  Eusta- 
chian orifice  on  its  lower  or  open  side.  The  curve  of  the  catheter  is 
such  that  when  the  curved  portion  catches  on  the  septum  the  tip  will 
be  far  enough  behind  the  margin  of  the  hard  palate  to  enter  the  Eu- 
stachian orifice.  We  may  also  withdraw  the  catheter  with  its  beak 
down  until  the  latter  catches  on  the  posterior  margin  of  the  hard 
palate  and  then  rotate  outward  through  90°,  but  this  plan  is  not  so 
sure  on  account  of  the  difficulty  of  distinguishing  between  the  pos- 
terior margins  of  the  hard  palate  and  of  the  aponeurosis  of  the  soft 
palate. 

Just  behind  the  prominence  caused  by  the  pharyngeal  orifice  is  a 
depression  in  the  wall  of  the  pharynx,  the  fossa  of  Rosenmuller.  This 
may  be  mistaken  for  the  opening  of  the  tube,  for  it  may  readily  engage 
the  tip  of  the  catheter,  and  it  is  the  principal  cause  of  error  in  passing 
the  catheter.  When  the  catheter  is  in  Rosenmiiller's  fossa,  the  patient 
gives  a  sudden  start  when  air  is  forced  through  it,  but  when  the 
catheter  is  in  the  Eustachian  tube  the  surgeon  can  hear  the  entrance 
of  air  into  the  ear  by  means  of  a  tube  passing  between  the  patient's 
meatus  and  his  own.  This  fossa  is  greatly  deepened  when  tlie 
pharyngeal  (Luschka's)  tonsil,  internal  to  it,  is  enlarged. 

In  cases  of  denfncsfi  associated  with  In/pertrophy  of  the  /oh.sjV,  which 
lies  below  the  soft  palate,  the  pressure  of  the  enlarged  tonsil  itself  may 
possibly  be  the  cause  of  the  obstruction  of  the  tube,  but  the  latter  is 
more  often  due  to  the  associated  hypertropiiy  of  the  neighboring 
adenoid  tissue  and  of  that  in  the  mucosa  of  the  tube  near  the  orifice, 
The  movement  of  the  cilia  of  the  epithelium  which  lines  the  tube 
is  toward  the  pharynx.  The  lymphatics  of  the  external  and  mid- 
dle ear  and  of  the  Eustachian  tube  enter  glands  near  the  angle  of  the 
jaw. 


REGKfS   Tin:  OF    ORBIT  AM)   EYE.  59 

THE  FACE. 

Region  of  the  Orbit  and  Eye. 

The  eyebrows  are  composed  of  layers  similar  to  those  of  the  scalp 
except  that  the  subcutaneous  layer  contains  but  little  fat  and  the  mus- 
cular layer  includes  throe  intersecting  muscles,  the  corrugator  super- 
cilii,  the  occipito-frontalis  and  the  orbicularis  palpebrarum  muscles. 
Incisions  made  here  should  be  parallel  to  the  long  axis  of  the  eyebrow 
so  that  the  cicatrix  may  be  hidden  in  the  hairs.  Blows  or  falls  may 
produce  a  icound  made  l)y  the  supraorbital  margin  cutting  through 
from  within  and  often  appearing  like  an  incised  wound.  The  eye- 
brows, especially  their  inner  end  or  head,  correspond  to  the  frontal 
sinuses.  The  outer  end  or  tail  of  the  eyebrows,  at  the  level  of  the  ex- 
ternal angular  process,  is  a  favorite  situation  for  dermoid  cyffs,  which 
are  here  due  to  a  portion  of  skin  being  shut  in  below  the  surface  in 
the  closure  of  the  outer  end  of  the  orbito-nasal  fissure.  Such  cysts  are 
beneath  and  do  not  involve  the  skin  and  often  indent  the  bone.  The 
hairs  of  the  eyebrows  help  to  shade  the  eyes,  to  protect  them  from 
dust  and  to  deflect  the  perspiration  of  the  forehead  beyond  their  limits. 
The  corrugator  muscle  is  supplied  by  the  facial  nerve  and  is  affected  in 
facial  paralysis.  The  lymphatics  of  the  outer  half  run  to  the  parotid 
nodes,  those  of  the  inner  end  to  the  submaxillary  nodes. 

The  eyelids  (Fig.  14)  serv^e  to  cover,  protect  and  keep  moist  the 
eyes.  Examining  the  component  layers  successively  we  find  that  (1) 
the  skin  is  very  thin  and  delicate  so  that  extravasation  of  blood  beneath 
it  shows  through  as  a  ^^ black  eye"  almost  at  once.  It  presents  numer- 
ous transverse /oW.s-  in  line  with  which  all  incisions  in  the  lid  should  be 
made.  These  folds  are  most  marked  beyond  the  tarsal  cartilages  and  in 
the  ujij)er  lid  one  deeper  than  the  rest  (superior  palpebral  fold),  divides 
the  lid  into  two  parts,  a  lower  smoother  tarsal  portion  covering  the  globe, 
and  an  upper  more  wrinkled  orbital  portion  covering  the  soft  parts  of  the 
orbit.  The  folds  of  skin  are  due  to  its  laxity  and  its  lo<)se  attachment 
to  the  muscular  layer  by  (2)  a  thin  layer  of  fatless  connective  tissue. 
The  laxity  of  the  skin  makes  it  well  adapted  for  plastic  operations.  By 
reason  of  its  loose  attachment  it  is  readily  affected  by  the  traction  of 
cicatrices  below  the  lower  lid  which  draw  the  latter  away  from  the 
globe  and  thus  produce  ectropion  or  eversion  of  the  lid.  Epitlielioma 
frequently  attacks  the  lids  and  may  in  time  produce  ectropion.  The 
skin  contains  some  pigment  which  helps  to  protect  the  eye  from  bright 
light,  and  the  yellowish  plaques  sometimes  seen  in  the  skin  in  old 
people,  especially  near  the  inner  canthus,  are  due  to  an  accumulation 
of  sebaceous  matter  in  the  numerous  sebaceous  glands. 

3.  The  orbicularis  palpebrarum,  or  sphincter  muscle  of  the  lids,  by 
its  action,  closes  the  lids,  raising  the  lower  and  depressing  the  upper 
one.  As  it  is  attached  internally  to  the  firm  tendo  oculi  its  contrac- 
tion draws  inward  the  outer  commissure  which  is  attached  externally 
by  the  less  firm  external  tarsal  ligament.     This  inward  motion  of  the 


60 


THE  HEAD  AND  NECK. 


eyelids  helps  to  wash  the  lachrymal  secretion  towards  the  inuer  canthus 
and  the  puncta  lachrymalia.  The  contracture  of  the  muscle  {blepharo- 
spasm) closes  the  lids  continuously  and  may  reach  such  a  degree  as  to 
invert  the  free  border  of  the  lids  (entropion),  the  pressure  of  which 
may  occasion  ulceration  of  the  cornea.  The  muscle  is  supplied  by  the 
facial  nerve  in  paralysis  of  which  the  ability  to  wink  or  close  the  eye- 
lids is  lost. 

Fig.  14 


i^Sr  fc,*^  ^-*    •* *<  ^' I.  tod ^ *  *r 


UPPER     MARGIN    OF    ORBIT 


/&-- ADIPOSE   TISSUE 


LEVATOR     PALPEBR>E 
SUPERIORIS 


MUSCULAR    TENDON 
OF    LEVATOR 

FORNIX    OF    CON- 
JUNCTIVA 


MEIBOMIAN   GLANDS 
TARSUS 


GLAND   OF   MOLL 


Upper  lid  in  sagittal  section.     (After  Merkel. ) 

4.  Separating  the  muscle  from  the  tarsi  is  a  thin,  loose  connective 
tissue  layer.  This  is  readily  hifiltrated  by  oedema,  inflammatory  or 
bloody  exudation,  etc.,  which  cause  a  rapid  and  considerable  swelling 
of  the  lids.  In  the  puffiness  of  the  lids  so  common  in  Bright's  dis- 
ease and  some  other  conditions  the  swelling  is  largely  in  this  layer. 
This  layer  also  includes  fibers  from  the  fibrous  expansion  of  the  levator 
palpebrfe  muscle  in  the  upper  lid  and  of  the  corresponding  rectus 
muscle  in  both  lids. 


THE  EYELIDS.  61 

5.  The  stiff  plates  of  closely  felted  connective  tissue  called  the 
" tar -al  cartilages"  form  the  framework  of  those  parts  of  the  lids  which 
cover  the  globe.  The  opposing  maiyiini  are  free,  except  internally  and 
externally  where  they  unite  to  form  the  cmit/ii,  the  other  margins  are 
connected  with  the  periosteum  at  the  margin  of  the  orhit  by  the  pal- 
pebral faacia.  The  latter  covers  the  soft  i)arts  of  the  orbit  and  is  firm 
enough  to  prevent  an  extravasation  within  the  orbit  from  reaching  the 
surface  of  the  eyelids.  The  breadth  of  the  upper  tarsus  (10  mm.)  is 
about  double  that  of  the  lower  and  opposes  the  examination  of  the 
inner  surface  of  the  u|>per  lid  while  the  inner  surface  of  the  lower  lid 
is  readily  exposed  by  drawing  down  that  lid.  To  expone  the  inner 
surface  of  the  upper  lid,  as  in  the  search  for  foreign  bodies,  we  direct 
the  patient  to  look  down  and  then  seize  the  eyelashes  and  the  edge  of 
the  lid  and  evert  it  by  raising  up  the  free  border  while  the  upper  end 
of  the  lid  is  pressed  down  by  a  match,  small  pencil,  etc.  Attached  to 
the  upper  border  of  the  upper  tarsus  and  the  anterior  surface  just  below 
this  point  is  the  levator  muscle  "which  raises  this  lid.  As  it  is  supplied 
by  the  third  nerre  this  lid  droojvs  (ptosis),  -when  that  nerve  is  paralyzed. 
Incisions  to  reach  the  cavity  of  the  orbit  are  made  beyond  the  limits 
of  the  tarsi;  through  the  palpebral  fascia,  usually  that  of  the  upper 
lid.  The  two  tarsi,  where  they  join  internally  and  externally,  are 
connected  with  the  inner  and  outer  orbital  margins  by  the  palpebral 
lif/aments.  Of  these  the  inner,  tendo  oculi,  is  attached  by  two  limbs  to 
the  two  ridges  bounding  the  lachrymal  groove  and  thus  embraces  the 
lachrymal  sac  to  which  it  is  an  important  guide.  It  lies  in  front  and 
external  to  the  lachrymal  sac  at  the  junction  of  its  middle  and  upper 
thirds  and  can  be  made  ])rominent  by  drawing  the  lids  outwards. 

6.  The  conjunctival  mucous  membrane  adheres  closely  to  the  back  of 
the  tarsi  [palpebral  conjunctira).  This  part  of  it  is  thick,  red  and  vas- 
cular and  its  degree  of  redness,  in  the  absence  of  inflammation,  is  taken 
as  an  indication  of  the  presence  or  absence  of  aniemia.  In  (/ranular 
lids  the  little  elevations  known  as  granulations  are  due  to  enlarged 
nodules  of  adenoid  tissue,  mucous  follicles  and  j)apill8e.  From  the 
contraction  of  the  new  connective  tissue  found  abundantly  in  the  mem- 
brane in  such  conditions  the  edge  of  the  lids  may  be  inverted  (entro- 
pion). The  rich  sensory  nerre  >^Hpplii,  from  the  ophthalmic  division 
and  the  infraorbital  branch  of  the  tilth  nerve,  e\j)lains  the  excpiisite 
pain  caused  by  conjunctivitis  or  the  presence  of  a  foreign  body.' 

The  conjunctiva  is  reflected  from  the  back  of  the  lids  onto  the  sur- 
face of  the  globe,  the  anterior  third  of  which  it  covers. 

The  ]>()int  of  this  reflection  is  called   the  fornix.      The   uj>pcr  fornix 

is  the  deeper,  extending  above  the  corres{)onding  tarsus  to  the  junction 

of  the  inferior  three-fourths  with  the  superior  fourth  of  the  upper  lid. 

Hence  iiwisioux  to  reach  the  orbital   contents  are  made  in   the  upper 

fourth  of  the  lid  so  as  to  avoid  the  conjunctiva.      The  external  canthus 

'  After  tlie  operation  of  removal  of  the  (•'(i.iHrridii  (/(Dif/lion  tlie  loss  of  sensjition  of  the 
conjunetivii  renders  tlie  presence  of  the  dust  and  foreign  i)odies  painless,  but  at  the  same 
lime  the  latter  set  nj)  an  inflammation  of  the  conjunctiva  so  that  the  eye  has  to  be 
kept  closed  and  protected. 


62  THE  HEAD  AND  NECK. 

is  several  millimeters  from  the  outer  margin  of  the  orbit  and  the  con- 
junctiva extends  beneath  the  lids  here  as  an  external  cul  de  sac  or 
fornix.  It  is  in  one  of  the  cul  de  sacs,  superior,  external  or  inferior, 
that  foreign  bodies  are  likely  to  be  lodged.  To  discover  and  remove 
such  bodies  the  inferior  and  external  fornices  can  be  readily  explored 
by  drawing  the  lids  downward  or  outward  respectively,  while  the 
upper  fornix  may  be  explored  by  everting  the  lid  as  described  above, 
or  the  foreign  body  may  often  be  removed  by  pulling  down  the  upper 
lid  so  that  its  inner  surface  is  wiped  off  on  the  outer  surface  of  the 
lower  lid.  At  the  inner  canthus,  which  reaches  to  the  inner  margin  of 
the  orbit,  is  an  island  of  modified  skin,  the  caruncle,  and  external  to 
this  the  conjunctiva  presents  a  small  vertical  semilimar  fold,  the  homo- 
logue  of  the  third  eyelid  or  membrana  nictitans  of  birds. 

The  conjunctiva  covering  the  fornices  and  globe  (ocular  conjunctiva) 
is  thin  and  loosely  attached  so  that  it  is  freely  movable,  which  is  of 
great  value  in  some  operations.  Some  of  the  vessels  seen  through  the 
ocular  conjunctiva  belong  to  the  underlying  sclerotic,  as  can  be  shown 
by  their  remaining  stationary  when  the  conjunctiva  is  moved  over 
them.  This  part  of  the  conjunctiva  has  but  little  vascularity,  unless 
it  is  inflamed,  so  that  the  white  color  of  the  sclerotic  shows  through  it. 
The  looseness  of  the  subconjunetival  tissue  over  the  globe  favors  the 
development  of  (edema,  which  may  reach  such  an  extreme  degree 
that  the  eye  cannot  be  closed,  and  the  cornea  is  partly  or  entirely 
covered.  It  also  favors  the  occurrence  of  subconjunctival  ecchymoses 
which  may  be  due  to  the  giving  way  of  one  of  the  poorly  supported 
vessels,  as  in  severe  vomiting  or  a  paroxysm  of  whooping  cough,  or  to 
an  extravasation  from  a  fracture  of  the  base  of  the  skull  involving 
the  orbital  roof.  One  peculiar  feature  of  subconjunctival  ecchymoses 
is  the  fact  that  they  retain  their  scarlet  color,  owing  to  the  thinness  of 
the  conjunctiva  which  allows  the  air  to  reach  the  blood  and  keep  it 
oxygenated.  Although  the  conjunctiva  is  normally  very  thin  it  may 
hypertrophy  in  the  form  of  a  vascular  triangle  (pterygium)  the  base 
of  which  is  directed  toward  one  of  the  canthi,  the  apex  to  and  finally 
over  the  pupil. 

The  arteries  of  the  eyelids,  derived  from  the  lachrymal  and  palpe- 
bral branches  of  the  ophthalmic,  form  arches  near  the  borders  of  the 
tarsus  in  the  connective  tissue  layer  beneath  the  muscle.  The  veins 
enter  into  branches  of  tlie  ophthalmic  at  the  outer  canthus  and  into  the 
veins  of  the  face  at  the  inner  canthus.  Thus  the  veins  of  the  eyelid 
and  through  them  those  of  the  face  communicate  with  the  cavernous 
sinus  through  the  ophthalmic  vein,  so  that  an  infection  of  the  eyelid  or 
face  is  capable  of  causing  sej)tic  thrombosis  of  the  cavernous  sinus. 

The  free  border  of  the  eyelids,  averaging  30  mm.  in  length,  consists 
of  a  ciliary  portion  (outer  five-sixths)  and  a  lachrymal  portion  (inner  one- 
sixth)  separated  by  the  projecting  papilla  on  which  is  the  punctum. 
The  ciliary  portion  is  flattened  and  2  ram.  thick.  The  two  or  three 
rows  of  obliquely  implanted  hairs  which  it  presents  anteriorly  may 
occasionally  project  internally  and  irritate  the  conjunctiva  and  cornea. 


PLATE    I  I. 


FIG.  15. 


LACHRYMAL    SAC 
TFNDO    OCULI 

CANALICULUS 
CARUNCLE 


PUNCTUM 


TENDO    OCULI,    RE- 
FLECTED   PORTION 
MUSCLE    OF    HORNER 


Horizontal    section    of    lacrymal     sac     passing     through     the 
tendo  oculi.    Diagrammatic.     (Testut.) 


THE  LACHRYMAL   M'l'Ml ATI'S.  63 

This  may  be  due  to  a  vicious  iuiplantation  (trichiasis)  or  to  a  general 
inversion  of  the  border  (entropion).  Intlaniuiation  in  the  hair  follicles, 
their  sebaceous  glands  or  the  Meibomian  glands,  but  especially  in  the 
sebaceous  glands,  constitutes  a  "  sti/e."  The  secretion  of  the  Meibo- 
mian (/lands  lubricates  the  cornea  and  renders  it  waterproof.  When 
this  secretion  is  retained  in  one  of  the  glands  it  gives  rise  to  a  'tarsal 
tumor.''  The  border  of  the  lid  with  its  sluggish  terminal  circulation, 
its  junction  of  sivin  and  mucous  membrane,  its  moist  surface  and 
numerous  glands  is  frequently  the  seat  of  troublesome  inflamma- 
tion. 

The  Lachrymal  Apparatus. — The  lachrymal  gland  reaches  to 
within  a  few  millimeters  of  the  anterior  orbital  margin  at  the  upper 
and  outer  angle  and  lies  between  the  superior  and  external  recti.  It 
is  enclosed  in  a  fibrous  capsule  derived  from  the  orbital  periosteum  so 
that,  according  to  Tillaux,  it  may  be  opened  or  removed,  without 
opening  the  post-ocular  space,  by  incising  the  periosteum  at  the  margin 
of  the  orbit  and  stripping  it  off  from  the  roof  until  we  reach  a  point 
just  above  the  gland.  Cysts,  tumors  and  abscesses  may  occur  here. 
A  lower  accessory  portion  of  the  gland  lies  above  the  outer  third  of  the 
upper  conjunctival  fornix  where  also  the  ducts  of  the  gland  open. 
From  this  point  the  tears,  neutral  in  reaction,  fall  over  the  front  of  the 
eyeball,  flusliing  it  of  dust,  etc.,  and  are  swept  inward  to  the  puncta 
by  the  contractions  of  tlie  orbicularis  muscle. 

Each  papilla  curves  backward  to  the  surface  of  the  eye  and  presents 
at  its  summit  the  punctum  or  commencement  of  the  canaliculus  (Fig. 
16).  The  position  of  the  puncta  in  close  apposition  with  the  eye  is 
well  adapted  for  draining  off  the  tears  wliich  collect  here.  Sometimes 
the  puncta  are  displaced  forward  so  that  the  tears  collect  and  overflow 
{epiphora)  onto  the  cheek.  This  may  occur  when  the  lower  punctum 
only  is  displaced,  as  in  swelling  of  the  lid,  entropion  or  ectropion. 
Among  the  causes  of  the  latter  is  a  relaxed  condition  of  the  orbicularis, 
present  in  old  age  or  in  facial  paralysis  when  this  muscle  is  paralyzed, 
for  the  puncta  and  inner  margin  of  the  lids  are  held  in  apposition  with 
the  surface  of  the  globe  by  a  specialized  part  of  the  orbicularis  muscle, 
known  as  the  muscle  of  Horner  or  the  tensor  tarsi.  This  muscle  arises 
from  the  lachrymal  bone  behind  the  posterior  or  reflected  limb  of  tlie 
tendo  oculi  and  from  the  latter  and  is  attached  to  the  back  of  tlie  inner 
end  of  the  tarsi  as  far  as  the  papilla?.  By  drawing  inward  and  back- 
ward the  outer  end  of  the  tendo  oculi  and  thereby  the  tarsi,  it  may  also 
compress  the  lachrymal  sac.  It  may  also  help  to  open  or  keep  open 
the  canaliculi  (Fig.  lo). 

The  loicer  punctum  is  slightly  external  to  and  Uirger  than  the  upper 
and  both  are  held  open  by  a  firm  fibrous  ring.  The  canaliculi  run  at 
first  vertically  and  then  bend  sharply  and  run  nearly  horizontally  in- 
ward, a  point  to  be  remembered  in  passing  a  stylet  or  in  injections. 
Obstruction  of  the  ])tnu'ta  or  canaliculi,  due  to  inflammation  or  to  com- 
pression by  an  inflammation,  etc.,  external  to  tiiem  is  ant)ther  cause 
of  the  overflow  of  tears. 


64 


THE  HEAD  AND  NECK. 


The  lachrymal  sac,  lodged  in  the  lachrymal  groove  just  internal  to 
tiie  inner  cantlius,  receives  the  canaliouh  antero-externally  and  has  the 
following  ((Oidmarks.  The  inner  ridge  bounding  the  lachrymal  groove 
is  continuous  with  the  inferior  orbital  margin  and  can  be  palpated. 
By  drawing  the  eyelids  externally  the  tendo  oculi  can  be  seen  and  felt 
crossing  in  front  of  the  sac  at  the  junction  of  the  upper  and  middle 
thirds.  Consequently  it  is  below  the  tendo  oculi  and  external  to  the 
above  ridge  that  we  incixe  to  open  the  antero-external  aspect  of  the 
lachrymal  sac  in  case  of  lachrymal  tumor,  to  give  vent  to  pus  or  to 
introduce  instruments.  A  lachrymal  abscess  always  points  below  the 
tendon.  In  introducing  stylets,  etc.,  it  is  important  to  know  the 
course  and  direction  of  the  lachrymal   sac  and   its   continuation,  the 

Fig.   16. 


PCNING    OF    CANALIC. 
NTO    LACHRYMAL   SAC 


NF.    ORIFICE    OF 

NASAL    DUCT 
IMF.   TURBINATE     BONE 


Transverse  obIi(iue  section  ilnough  nasal  canal,  viewed  fnmi  in  front.     (Tkstut.) 


nasal  duct.  These  together  are  not  quite  straight,  but  slightly  curved 
so  as  to  be  concave  posteriorly  and  are  directed  downward,  backward 
and  slightly  outward.  Together  they  average  a  little  over  one  \nrh  in 
length  (2G  mm.)  of  which  the  sac  represents  the  upper  two-fifths. 
Lachrymal  tumor  is  usually  due  to  a  chronic  inflammation  and  thicken- 
ing of  the  lining  mucous  membrane.  It  forms  a  swelling  at  the  inner 
corner  of  the  orbit  and  its  evacuation  is  occasionally  followed  by  a 
lachrymal  fistula.  V<dves  occur,  but  are  not  constant,  at  the  opening 
of  the  canaliculi  into  the  sac  and  between  the  sac  and  the  nasal  duct. 
According  to  some  the  latter,  which  is  the  less  constant  valve,  may  be 
responsible  for  some  cases  of  lachrymal  tumor. 

The  lachrymal  sac  is  enclosed  by  a  fibrous  sheath  derived   from   the 
splitting  of  the  periosteum  at  the  ridges  which  bound  its  groove.     The 


THE   OUBIT.  65 

tendo  ociili  is  a  thickening  of  this  capsule.  Tiiis  sheath  limits  the 
distension  of  the  sac  which  may  reach  G  mm.  antero-prj<teriorly  and 
4  mm,  transverely.  Tlie  nasal  duct,  lodj^ed  in  the  lachrymal  canal,  is 
about  3  mm.  in  d iameter  and  its  narrowest  point  is  at  the  junction  with 
the  sac.  It  is  the  unobliterated  part  of  the  orbital  fissure  and  opens 
bv  a  vertical  .slit-lUce  oijeninr/  into  the  inferior  meatan  of  the  nose.  It 
is  difficult  to  find  and  enter  this  openint^  in  the  cadas'er,  hence  catheter- 
ization from  below  in  the  living  subject  is  too  difficult  to  be  advisable. 
This  hirer  opening  is  situated  about  3  cm.  behind  the  free  margin  of  the 
ala  of  the  nose,  8-10  mm.  behind  the  anterior  end  of  the  inferior  tur- 
binate bone,  in  the  angle  between  the  short,  obli(jne,  anterior  limi)  and 
the  longer  and  more  horizontal  posterior  limb  of  this  bone  and  in  the 
angle  between  the  lateral  wall  of  the  nose  and  the  inferior  turbinate 
bone. 

All  the  ducts  by  which  the  tears  are  removed  are  he/rl  open,  the  puncta 
by  the  fibrous  rings  surrounding  them,  the  canaliculi  by  the  tensor  tarsi 
muscle,  the  lachrymal  sac  by  its  fibrous  sheath  and  the  tendo  oculi, 
the  nasal  duct  by  its  bony  walls.  This  circumstance  favors  the  theory 
of  Sedillot,  which  exjilains  the  passage  of  tears  by  the  vacuum  produced 
by  the  air  passing  across  the  lower  opening  of  the  duct  on  the  prin- 
ciple of  the  mercury  vacuum  pump.  It  may  also  be  said  that  the 
process  of  winking,  due  to  the  action  of  the  orbicularis,  keeps  the 
puncta  applied  to  the  eye,  holds  open  the  canaliculi  by  means  of 
the  tensor  tarsi  and  compresses  the  sac  so  as  to  force  the  tears  down- 
ward, as  the  opening  into  the  canaliculi  is  guarded  by  a  valve.  After 
such  a  compression  the  emptied  sac  exerts  a  suction  to  draw  the  tears 
into  it.  By  means  of  these  ducts  the  mucous  membrane  of  the  nose 
and  eye  are  continuous  and  inflammation  may  spread  from  one  to  the 
other.  Inflammation  of  the  sac  and  duct  is  usually  an  extension  from 
an  inflammation  of  the  nasal  mucosa. 

The  Orbit. 

The  antero-posterior  axis  of  the  pyramidal  orbital  cavity  is  directed 
obliquely  forward  and  outward  and  measures  If  inches.  The  inner 
walls  though  convex  laterally  are  nearly  parallel  with  one  another,  a 
fact,  like  that  of  the  parallelism  of  the  optic  axis,  which  is  ])eculiar  to 
man.  The  inner  wall,  floor  and  roof  are  very  thin.  The  inner  wall 
separates  the  orbit  from  the  ethmoid  cells  and  nasal  fossa,  the  floor 
from  the  maxillary  antrum  and  the  roof  from  the  cranial  cavity. 
Foreign  bodies,  such  as  foils,  umbrellas,  canes  or  sharp  sticks,  thrust 
into  the  orbit  have  readily  pendraled  through  these  thin  walls  into  the 
ethmoidal  cells,  the  nose,  the  antrum  or  the  cranial  cavity.  These 
walls  otfer  little  resistance  to  (uniors  extending  into  the  orbit  from  the 
surrounding  cavities  or  vice  versa.  This  is  especially  seen  in  tumors 
of  the  antrum  which  elevate  the  floor  of  the  orbit,  destroy  the  inter- 
vening bone,  and  displace  forwards  the  orbital  contents,  causing 
exophthalmos. 
5 


66  THE  HEAD  AND  NECK. 

The  presence  of  the  bony  groove  and  canal  for  the  infraorbital  nerve 
in  the  floor  of  the  orbit  should  be  borne  in  mind,  for  the  nerve  is  liable 
to  be  pressed  upon  by  tumors  of  the  orbit  or  antrum.  There  are 
various  channels  of  coniiiiinication  between  the  orbit  and  the  surround- 
ing cavities.  It  communicates  with  the  cranial  cavity  through  the 
optic  foramen  and  the  sphenoidal  fissure  at  the  apex  of  the  orbit,  with 
the  nose  through  the  nasal  duct  and  with  the  zygomatic  and  spheno- 
riiaxillarii  fossce  through  the  sphenomaxillary  fissure.  Through  this 
fissure  blood  may  find  its  way  into  the  orbit  after  violent  blows  on  the 
temporal  region. 

At  each  angle  between  the  orbital  walls  there  is  some  point  of 
interest.  Thus  at  the  sitpero-internal  angle  are  the  ethmoidal  canals 
(and  the  pulley  for  the  superior  oblique) ;  at  the  infero-interncd  angle 
the  lachrymal  caned ;  at  the  i7ifero-external  angle  the  sphenomaxillary 
fissure  and  at  the  super o-exierncd  the  depression  for  the  lachrymal  gland. 
The  anterior  end  of  the  sphenomaxillary  fissure,  through  which  we 
pass  the  flexible  saw  in  removal  of  the  upper  jaw,  is  15  mm.  from  the 
margin  of  the  orbit.  The  outer  walls  are  inclined  to  the  sagittal  plane 
at  an  angle  of  nearly  45°,  hence  the  interior  of  the  orbit  is  most  con- 
veniently reached  by  incisions  external  to  the  globe  between  it  and  the 
outer  wall.  The  bones  of  the  orbit  are  especially  liable  to  develop 
"  ivory  "  exostoses.  The  largest  part  of  the  orbit  is  not  at  its  margin 
but  about  1  cm.  behind  it. 

The  orbital  margin  is  prominent  and  easily  felt  above,  below  and 
externally,  more  rounded  and  less  readily  palpable  internally.  The 
eye  is  well  protected  by  this  prominent  rim.  As  the  base  of  the  orbit 
is  bevelled  so  that  the  plane  of  its  margin  looks  outward  as  well  as  for- 
ward the  range  of  vision  is  notably  increased  laterally  but  at  the  same 
time  the  eye  is  more  vulnerable  from  the  outside.  Mesially  the  eye 
is  protected  from  injury  mainly  by  the  nose.  On  the  supraorbital 
margin  at  the  junction  of  the  inner  and  middle  thirds  is  the  supra- 
orbital notch  or  foramen  through  which  the  supraorbital  nerves 
emerges  from  the  orbit.  The  horizontal  diameter  of  the  orbital  margin 
is  about  1^  inches,  its  vertical  diameter  a  little  over  1^  inches;  the 
similar  diameters  of  the  globe  are  respectively  24  and  23  mm. 

The  Contents  of  the  Orbit. — These  include  the  globe  and  its  ves- 
sels, nerves  and  muscles  embedded  in  a  quantity  of  fat.  (Fig.  17.)  In 
addition  there  is  an  important  aponeurotic  capsule,  supporting  the 
globe  and  limiting  the  action  of  its  muscles.  This  is  the  capsule  of 
Tenon  or  orbital  aponeurosis  whose  prolongations  connect  it  with  the 
muscle  sheaths  and  the  orbital  periosteum.  (Fig.  18.)  The  capsule 
of  Tenon  proper  is  that  part  of  the  fascia  of  the  orbit  which  surrounds 
the  posterior  |,  or  the  sclerotic  portion  of  the  globe.  It  extends  for- 
ward as  far  as  the  cornea  and  is  continued  backward  around  the  optic 
nerve,  with  whose  sheath  it  fuses.  In  order  therefore  to  reach  the 
sclerotic,  as  in  a  tenotomy  of  the  recti  tendons  for  strabismus,  we  must 
cut  through  two  layers,  the  ocular  conjunctiva  and  Tenon's  capsule. 
This  capsule  separates  the  globe  from  the  fat,  etc.,  in  the  posterior 


PLATE 


FIG.  17. 


SUP.    RECTUS 
MUSCLE 


LEVATOR     PALPE- 
3RAe    MUSCLE 


SUP.  OBL 
MUSC 


INT.    RECTUS        ^  \  I 

MUSCLE  IKWM) 

ET  H  M  O I  D  ^^r't     Mil 
CELLS  l.i.U2 


TEMPORAL    MUSCLE 

LACHRYMAL    CLAN  D 
EXT.    RECTUS 


INF.   OBLIQUE 
MUSCLE 


LLARY 
US 


INF     RECTUS 

MUSCLE       INFRAORBI- 
TAL   NERVE 


Frontal  section  of  left  eye.     (Merkel.) 


FIG.  18. 


TENDON    OF    INT. 

RECTUS    MUSC. 
SHEATH    OF    INT. 

RECTUS    MUSC. 


CAPSULE    OF 


Partly  diagrammatic  horizontal  section  of  the  right 
orbit  and  eye  to  show  the  arrangement  of  the  capsule  of 
Tenon.     Lower  segment  of  the  section.     iTestut. ) 


THE  CONTENTS  OF  THE  ORBIT.  67 

half  of  the  orbit  ;  in  fact  with  its  prolongations  it  forms  a  kind  of 
septum  between  the  globe  in  front  and  the  rest  of  the  orbital  contents 
behind.  The  inner  surface  of  this  capsule  is  loosely  connected  with 
the  sclerotic  by  lax  and  delicate  areolar  tissue  and  is  smoothly  lined 
bv  endothelium.  It  is  in  fact  the  outer  wall  of  a  large  lymph  space 
and  forms  a  species  of  socket  in  which  the  globe  moves  without 
friction. 

In  order  to  reach  their  insertions  in  the  sclerotic  coat  of  the  globe 
the  tendons  of  the  ocular  muscles  must  pass  through  this  capsule. 
Where  they  do  so,  opposite  the  equator  of  the  globe,  the  aponeurosis 
invests  the  muscle  tendons  in  a  fibrous  sheath  which  is  prolonged  for- 
ward to  their  insertions  and  backward  toward  the  middle  of  tiie  orbit 
where  it  fuses  with  the  proper  sheaths  of  the  muscles,  A  small  se- 
rous bursa  is  formed  on  the  anterior  surface  of  each  tendon.  In  con- 
sequence of  this  arrangement  of  the  jirolongations  of  the  capsule  the 
muscles  do  not  retract  to  their  limit  after  division  of  their  tendons, 
close  to  their  sclerotic  insertion,  but  are  held  by  the  capsular  prolon- 
gation. In  this  way,  after  tenotomy,  the  muscles  retain  a  hold  on  the 
globe  so  that  they  still  act  on  it  through  the  capsule.  Even  after 
enucleation  of  the  globe  the  muscles  retain  a  hold  on  the  capsule  and 
so  may  furnish  some  motion  to  the  stump  and  the  artificial  eye  which 
occupies  it.  In  addition  prolongations  pass  from  the  aponeurotic 
sheaths  of  the  recti  to  the  walls  of  tJie  orbit  a  little  behind  its  margin, 
where  they  are  continuous  with  the  orbital  periosteum.  Of  these  pro- 
longations or  bands  the  external  and  internal,  from  the  sheaths  of  the 
corresponding  recti  to  the  orbital  walls  behind  the  corresponding  pal- 
pebral ligaments,  are  the  best  developed.  They  are  known  as  the 
check  ligaments  for  they  check  excessive  outward  and  inward  rotation 
of  the  globe.  Together  with  that  part  of  the  capsule  connecting  them 
beneath  the  globe  they  have  been  called  by  Lockwood  the  suspensory 
ligament,  as  they  suspend  the  globe  as  in  a  hammock.  According  to 
Lockwood  it  is  important  to  preserve  the  attachments  of  this  ligament 
in  removing  the  maxilla  in  order  to  prevent  the  eyeball  from  sinking 
downward.  The  orbital  band  or  prolongation  from  the  superior  rectus 
to  the  orbital  walls  connects  the  latter  muscle  with  the  levator palpebrce 
just  above  it.  Hence  the  contraction  of  these  muscles  is  not  entirely 
independent  and  the  superior  rectus  is  to  a  slight  extent  an  elevator  of 
the  upper  lid  so  that  elevation  of  the  eye  and  of  the  lid  are  very  inti- 
mately associated  with  one  another. 

The  attachment  of  the  recti  muscles  to  the  orbital  walls  by  means  of 
the  prolongations  from  their  aponeurotic  sheaths  has  the  following 
practical  conserjurnces.  The  muscles  do  not  retract  far  when  divided 
and  they  are  held  away  from  the  globe  by  these  prolongations,  which 
act  like  pulleys,  so  that  the  nniscles  when  tliey  act  do  not  compress 
the  gl()l)e  as  they  otherwise  would.  Furthermore  on  account  of  the 
obliquely  forward  direction  of  these  prolongations  the  recti,  when  they 
act,  do  not  retract  the  globe  as  much  as  they  otherwise  would  and 
hence  do  not  overpower  the  oblique  muscles  which  act  weakly  as  pro- 


68  THE  HEAD   AXD  ^'ECK. 

trusors.     In  this  way  the  action  of  the  recti  is  confined  to  the  move- 
ments of  the  globe  on  its  various  axes. 

The  periosteum  lining  the  orbit  is  continuous  at  the  orbital  margin 
with  that  of  the  surface  of  the  face  and  cranium  and  at  the  sphenoidal 
fissure  and  the  optic  foramen  with  the  periosteal  layer  of  the  dura. 

The  muscles  of  the  orbit  are  inserted  into  the  sclerotic  about  one 
fourth  inch  from  the  cornea,  or,  according  to  Fuchs,  the  internal  rectus 
5.5  mm,,  the  inferior  6.5  ram.,  the  external  6.9  mm.,  the  superior  7.7 
mm.  from  the  corneal  margin.  The  points  of  insertion  form  a  spiral 
which,  commencing  with  the  internal  rectus  and  ending  with  the  supe- 
rior, gradually  reaches  further  from  the  edge  of  the  cornea.  The  tendons 
of  the  internal  and  external  recti  are  often  divided  for  strabismus  and 
are  reached  at  the  above  distances  from  the  corneal  margin  after  incis- 
ing the  conjunctiva  and  the  capsule  of  Tenon.  The  tendons  are  then 
hooked  up  with  a  blunt  hook  and  divided  close  to  their  sclerotic  attach- 
ment. In  enucleation  of  the  globe  this  is  repeated  with  the  four  recti 
tendons  after  incising  the  conjunctiva  and  capsule  of  Tenon  circularly 
a  little  outside  of  the  margin  of  the  cornea.  The  optic  nerve  is  then 
divided  by  curved  scissors  from  the  outside  of  the  globe.  The  latter 
may  be  enucleated  without  opening  the  posterior  compartment  of  the 
orbit.     The  width  of  the  thin  flat  tendons  varies  from  7  to  9  mm. 

Muscular  Actions.  —  If  the  antero-posterior  axis  of  the  orbit 
were  in  the  same  Hue  as  that  of  the  eyeball  the  superior  and  infe- 
rior recti  would  simply  elevate  and  depress  the  eye,  for  their  line  of 
action  is  in  line  with  the  axis  of  the  orbit,  but  as  their  line  of  action 
forms  an  angle  with  the  antero-posterior  axis  of  the  globe  and  passes 
internal  to  its  vertical  axis,  both  muscles  adduct  the  eye.  On  the 
other  hand  both  the  superior  and  inferior  oblique  abduct  the  eye  and 
the  former  depresses,  the  latter  elevates  it.  Hence  to  produce  simple 
elevation  or  depression  of  the  eye  the  superior  oblique  acts  with  the 
inferior  rectus  and  the  inferior  oblique  with  the  superior  rectus  to 
counteract  the  adduction  of  the  recti  muscles.  The  external  and  in- 
ternal recti  produce  simple  abduction  and  adduction  as  their  lines  of 
action  are  parallel  with  the  horizontal  plane  of  the  eye.  Abduction  is 
also  produced  by  both  oblique  muscles  acting  together  and  adduction 
by  the  superior  and  inferior  recti  acting  together.  In  case  of  weak- 
ness, paralysis  or  abnormal  length  of  one  muscle  the  opposing  muscle 
overacts  and  turns  the  eye  away  from  the  weaker  side  and  the  eye 
cannot  be  moved  to  the  full  extent  if  at  all  in  the  opposite  direction. 
Strabismus,  squint  or  cross  eye,  is  thus  produced.  If  the  patient 
tries  to  look  in  the  direction  of  the  affected  muscle  the  affected  eye 
fails  to  move,  so  that  the  eyes  are  directed  in  different  directions  and 
double  vision  results.  Double  vision  does  not  result  on  looking  toward 
the  side  to  which  the  affected  eye  is  kept  directed.  To  avoid 
double  vision  the  patient  turns  his  head  to  the  side  toward  which  the 
affected  muscle  can  not  move  the  eye  so  that  the  muscle  is  not  called 
upon  to  act.  Thus  if  the  right  external  rectus  is  paralyzed  the  right 
eye  is  directed  internally  and  the  patient  has  little  difficulty  in  look- 


THE   TIIIRI)   NERVE.  69 

ing  toward  the  left,  but  if  he  tries  to  look  toward  the  right  the  right 
eye  fails  to  be  abducted  and  remains  stationary.  Plence  the  head  is 
kept  constantly  turned  toward  the  right  to  allow  liim  to  look  in  this 
direction  for  he  can  move  b(^th  eyes  in  the  o|)posite  direction. 

To  Detect  the  Muscular  Paralysis  by  looking  at  the  patient's  face. — 
Ranney  has  given  the  rule  that  :  "  The  head  is  so  deflected  that  the 
chin  is  carried  in  a  direction  corresponding  to  the  action  of  the  affected 
muscles."  One  affected  with  strabismus  is  often  able  to  educate  him- 
self to  disregard  one  visual  image  ;  which  would  give  rise  to  double 
vision,  and  to  use  the  other  eye  as  the  "  working  eye."  This  is  espe- 
cially true  in  case  of  a  double  convergent  squint. 

The  superior  and  inferior  recti  are  supplied  by  the  same  nerve,  the 
third,  but  the  external  is  supplied  by  the  sixth  and  the  internal  by  the 
third  nerve.  Hence  strahmnus  from  weakness  or  paralysis  of  one  of 
two  opposing  muscles  is  usually  an  internal  or  external  one,  as  either  the 
internal  or  external  rectus  is  more  likely  to  be  affected  without  the  other. 
There  may  be  another  reason  why  double  convergent  ntrabif<iiius  is  a  par- 
ticularly common  form.  For  in  that  congenital  defect  of  the  eye  in 
which  the  rays  are  naturally  focused  behind  the  retina  (hypermetro- 
pia  or  far-sightedness)  the  ciliary  muscle  struggles  to  accommodate 
the  lens  so  as  to  properly  focus  the  rays.  This  action  of  accommoda- 
tion is  closely  associated  with  that  of  convergence  or  adduction,  for 
the  same  nerve  (third)  supplies  both  muscles,  so  that  a  certain  amount 
of  the  energy  employed  in  accommodation  passes  into  the  internal 
recti  and  the  child  comes  gradually  to  a  convergent  squint. 

Nerves  of  the  Orbit, — The  fibers  of  the  optic  nerves  decussate  in 
the  optic  commissure  so  that  the  inner  half  of  one  eye  may  work  in 
harmony  with  the  outer  half  of  the  other,  for  the  image  of  an  object 
on  one  side  of  the  main  axis  of  vision  is  received  on  the  opposite 
(inner  and  outer)  but  corresponding  side  (right  or  left)  of  both  eyes. 
When  therefore  the  optic  tract  of  one  side  is  paralyzed  by  pressure, 
etc.,  the  outer  half  of  the  retina  on  that  side  and  the  inner  half  of  the 
retina  on  the  opposite  side  are  blind,  and  objects  on  the  opposite  side 
from  the  lesion  can  not  be  seen  [Jinnidnop.sid).  The  optic  nerve  has 
been  severed  by  a  stab  wound  of  the  orbit  and  torn  across  or  pressed 
upon  in  fractures  of  the  orbit  or  of  the  small  wing  of  the  sphenoid. 
The  optic  nerve  is  accompanied  through  the  orbit  by  an  investment  of 
dura,  arachnoid  and  pia,  continued  IVom  the  cranial  cavity.  These 
hiyers  are  not  adherent  together  but  leave  a  potential  si)ace  between 
them  as  in  the  cranial  cavity.  In  this  respect  the  optic  ditlers  from  the 
other  cranial  nerves  from  the  third  to  the  twelfth.  Cases  of  sudden 
blindness  without  visible  changes  on  ophthalmoscopic  examination  are 
lo  bo  ex[)lained  by  a  hemorrhage  or  other  ctfusion  within  this  menin- 
geal sheath.  The  capsule  of  Tenon  is  continuous  with  this  sheath  at 
the  back  of  the  globe.  The  optic  nerve  occupies  tiic  posterior  half  of 
the  orbit. 

The  third  nerve  (motor  oculi)  sujip/lc,^  all  the  muscles  of  the  orbit 
except   the  external   rectus  and  the  superior  obliciue  and,  through  the 


70  THE  HEAD  AND  NECK. 

leDticular  gangliou,  it  supplies  the  ciliary  muscle  and  the  sphincter 
fibers  of  the  iris.  Many  of  the  actions  of  the  third  nerve  are  seen  in 
viewing  near  objects.  Thus  both  eyeballs  are  directed  inward  by  the 
internal  recti  acting  in  unison,  for  which  purpose  the  third  nerves  of 
the  two  sides  are  associated  at  their  origin  in  the  gray  matter  around 
the  aqueduct  of  Sylvius.  The  pupil  is  also  contracted  by  its  sphincter 
fibers  to  cut  oif  the  peripheral  rays  and  the  lens  is  made  more  convex 
by  the  ciliary  muscle  to  focus  the  divergent  rays. 

When  the  third  nerve  is  completely  paralyzed  the  upper  eyelid  droops 
(j)tosis)  from  paralysis  of  the  levator  j^alpebrse,  there  is  a  divergent 
squint  with  double  vision  (diplopia)  from  the  unopposed  action  of  the 
external  recti,  the  j)upil  is  dilated,  and  cannot  be  contracted  on  account 
of  paralysis  of  the  circular  fibers  of  the  iris  and  accommodation  for 
near  objects  is  lost  from  paralysis  of  the  ciliary  muscle.  Rotation  of 
the  globe  in  a  direction  outward  and  downward  is  still  possible  by 
means  of  the  superior  oblique  and  the  external  rectus  but  otherwise 
the  eye  is  motionless.  The  globe  may  protrude  somewhat  from  the 
relaxation  of  three  of  the  recti  muscles.  In  partial  paralysis  these 
symptoms  may  be  either  partly  developed  or  only  one  or  two  may  be 
present.  The  j)upil  is  contracted  not  only  in  viewing  near  objects  but 
also  under  the  influence  of  a  bright  light.  The  latter  contraction  is 
reflex,  the  former  is  a  matter  of  accommodation.  The  pupil  in  which 
the  reflex  contraction  is  absent  while  the  accommodation  contraction 
is  present,  as  in  locomotor  ataxia,  is  called  the  "  Argyll- Robertson 
pupil,'' ^ 

In  paralysis  of  the  fourth  nerve,  which  supplies  the  superior  oblique 
only,  there  may  be  little  change  in  the  mobility  of  the  globe  for  the 
function  of  this  muscle  may  be  performed  vicariously,  at  least  in  part. 
But  there  will  be  diplopia  in  certain  positions  of  the  head,  for  there  is 
deviation  of  the  eye  inward  on  lowering  the  object  viewed.  That  the 
muscles  of  the  two  sides  may  act  in  unison  the  fibers  of  the  two  nerves 
decussate  in  the  gray  matter  around  the  Sylvian  aqueduct. 

When  the  sixth  nerve  is  2)aralyzed.  there  is  convergent  strahismus  with 
consequent  diplopia  owing  to  the  paralysis  of  the  external  rectus,  which 
alone  it  supplies,  and  the  unopposed  action  of  the  internal  rectus.  As 
the  patient  is  unable  to  rotate  the  eye  directly  outward  the  head  is 
turned  outward  instead.  The  fibers  of  the  two  sixth  nerves  do  not 
decussate  at  their  origin  as  the  two  external  recti  do  not  need  to  act  in 
concert.  The  nucleus  of  the  sixth  nerve  is  connected  with  that  of  the 
third  nerve  of  the  opposite  side  by  fibers  which  pass  eventually  into 
the  internal  rectus  so  that  both  eyes  can  be  directed  to  the  right  or 
left  by  the  action  of  a  single  nucleus. 

Paralysis  of  all  the  oculomotor  nerves  indicates  a  lesion  which  is 
probably  at  their  central  origin  or  at  the  cavernous  sinus,  in  the  wall 
of  whicii  they  lie  near  together. 

When  the  ophthalmic  division  of  the  fifth  nerve  is  paralyzed  there  is 
anaesthesia  of  the  globe,  conjunctiva,  upper  eyelids  and  other  parts 
supplied.     Under  these  conditions  the  conjunctiva  and  cornea,  espe- 


VESSELS  OF  THE  ORBIT.  71 

ciallv  the  latter,  are  apt  to  be  the  seat  of  ulceration.'  Hence  after 
removal  of  the  Gasserian  ganglion  for  desperate  trigeminal  neuralgia 
the  eye  has  to  he  carefully  i)r()tefte(l  or  altogether  closed. 

The  supraorbital  branch  of  this  nerve,  which  suj)plies  the  scalp 
nearly  as  far  back  as  the  lambdoid  suture,  is  not  infrecjuently  the  seat 
of  neuralgia.  When  it  demands  operative  treatment  it  may  be  readily 
exposed  bv  a  horizontal  inri.sion  centering  at  the  junction  of  the  middle 
and  inner  thirds  of  the  supraorbital  margin,  where  the  notch  if  present 
can  be  felt.  Continued  i)ressure  on  the  nerve  at  this  point  may  be  used 
to  detect  a  person  shamming  insensibility  or  to  rouse  a  person  from 
alcoholic  coma.     No  malingerer  can  bear  the  pressure  for  long. 

The  effects  on  the  eye  of  a  p<tralysi.s  of  the  sympatlietic  fibers,  which 
reach  it  along  the  internal  carotid  from  the  cervical  sympathetic,  are 
as  follows.  Tiiere  is  some  drooping  of  the  upper  lid  from  a  paralysis 
of  the  unstriped  muscle  fibers  (superior  palpebral  muscle  of  Miiller) 
which  extend  from  the  under  surface  of  the  levator  palpebra  muscle 
to  the  upper  margin  of  the  tarsal  cartilage.  There  is  some  recession 
of  the  globe  which  is  explained  by  some  as  due  to  the  paralysis  of 
smooth  muscle  fibers  bridging  over  the  sphenomaxillary  fissure,  the 
orbitalis  muscle  of  Midler.  The  removal  of  the  cervical  sympathetic 
ganglia,  advised  and  practiced  for  the  treatment  of  exophthalmic 
goitre,  may  therefore  improve  the  exophthalmos  in  this  way.  The 
pupil  is  also  narrowed  and  loses  its  power  of  dilatation  by  the  paralysis 
of  the  radiating  dilator  fibers  of  the  iris.  The  caliber  of  the  blood 
vessels  of  the  orbit  has  not  been  observed  to  change  in  paralysis  of  the 
cervical  sympathetic. 

Damage  to  the  orbital  nerves  may  be  due  to  fractures  of  the  orbit  or 
the  base  of  the  skull,  wounds  of  the  orbit,  and  the  pressure  of  tumors, 
aneurisms  and  bloody  or  inflammatory  effusions  along  their  course  or 
at  their  origin.  The  sixth  nerve  is  more  liable  to  be  injured  in  fractures 
of  the  base  of  the  skull  on  account  of  its  mere  intimate  connection 
with  it. 

Vessels  of  the  Orbit. — The  arteries  are  small  and  seldom  give 
trouble  when  divided  in  enucleation  of  the  globe  for  they  can  l)e  readily 
compressed  against  the  bony  wall.  The  ethmoidal  arteries  may  be 
torn  in  a  fracture  of  the  anterior  cranial  fossa.  Pulsating  tumors  of 
the  orbit  may  be  due  to  a  traumatic  aneurism  of  an  t)rbital  artery,  to 
an  arterio-venous  aneurism  between  the  internal  carotid  artery  and  the 
cavernous  sinus  or  to  pressure  u])()n  the  ophthalmic  vein  by  an  aneurism 
of  the  internal  carotid.  In  these  pulsating  tumors  the  eye  is  also 
protruded.  Pressure  upon  the  ophthalmic  vein,  or  the  cavernous  sinus 
into  which  it  empties,  by  a  tumor  or  an  inflammatory  deposit,  etc., 
causes  a  venous  congestion  of  the  tributaries  of  the  vein.  This  conges- 
tion is  visible  through  the   ophthalmoscope   as  a  ^U'hoke  disc."     The 

'  This  is  due  partly  to  tiie  paralysis  of  tin-  tropiiic  ncrvu  fibers  contained  in  the 
nerve  ;  partly  to  the  ana-sthesia  whieii  allows  tiie  )>arts  to  be  readily  injured  as  there 
is  no  sensation  an<l  the  reflex  winkinir.  due  to  irritation  of  theeonjunetiva,  is  wanting  ; 
and  partly  to  tiie  loss  of  the  rellex  of  the  sensory  nerves  upon  the  caliber  of  the  blood 
vessels  so  that  the  jirotrress  of  inflammation  is  unopposed. 


72  THE  HEAD  AND  NECK. 

presence  of  such  a  condition  may  assist  in  the  diagnosis  of  a  supposed 
tumor  or  deposit  at  the  base  of  the  brain.  As  the  facial  vein,  through 
the  angular,  communicates  freely  with  the  ophthalmic  and  there  are  no 
valves  in  these  veins  the  venous  congestion  in  the  latter  vein  may  be 
relieved  through  the  former,  if  the  condition  has  come  on  slowly.  This 
same  free  communication  renders  serious  any  septic  condition  of  the 
face  in  the  neighborhood  of  the  facial  vein  (carbuncle,  erysipelas,  etc.), 
on  account  of  the  danger  of  .the  infection  extending  along  the  veins  to 
the  cavernous  sinus  and  setting  up  a  septic  sinus  thrombosis. 

The  amount  of  fat  (Fig.  17)  behind  Tenon's  capsule,  which  embeds 
the  other  structures  of  the  orbit,  is  partly  responsible  for  the  varying 
prominence  of  the  eyeball  in  diiferent  persons  or  the  same  person  at 
different  times.  The  absorption  of  this  fat  in  cases  of  wasting  disease 
or  prolonged  illness  causes  the  sunken  eye,  characteristic  of  such  con- 
ditions. This  loose  fat  allows  th?  ready  spread  of  orbital  abscess  which 
may  follow  injuries  or  inflammations  of  the  orbit,  the  globe  or  adjacent 
parts.  The  pus  may  occupy  the  entire  posterior  com])artment  of  the 
orbit  (/.  f.,  behind  the  capsule  of  Tenon)  and  displace  the  eyeball  for- 
ward, limiting  its  movements.  The  pressure  of  the  vessels  interferes 
with  the  venous  circulation  and  causes  great  redness  on  the  conjunctiva 
and  swelling  of  the  lids.  A  similar  effect  may  be  produced  by  ciiipJtt/- 
senid  of  this  fatty  tissue,  which  may  result  from  fracture  of  the  inner 
wall  of  the  orbit  involving  the  nasal  fossa  and  which  is  increased  in 
amount  on  blowing  the  nose.  This  fiit  also  furnishes  a  favorable  site 
for  the  growth  of  tumors  and  the  lodgment  of  foreign  bodies.  Some  of 
the  latter  are  of  remarkable  size  and  shape  and  they  sometimes  remain 
for  long  periods  of  time  without  causing  much  trouble.  For  example, 
a  case  is  described  by  Lawson  where  an  iron  hat  peg  three  inches  long 
lodged  in  the  orbit  for  several  days  without  the  patient  knowing  it. 
In  other  cases  suppuration  takes  place  and  nature  gets  rid  of  the  for- 
eign body  through  the  opening  or  incision  of  the  abscess.  In  a  remark- 
able case  of  this  kind  described  by  Furneaux  Jordan  a  man,  several 
weeks  after  threshing  wheat,  ejected  from  a  bed  of  ])us,  by  pressure  on 
the  lower  lid,  a  sprouting  grain  of  wheat  which  had  set  up  a  severe 
ophthalmia. 

THE   NOSE,  NASAL   FOSS^    AND   ACCESSORY 
SINUSES. 

Tiie  external  nose  is  largely  for  cosmetic  purposes,  a  fact  strikingly 
illustrated  by  the  hideous  appearance  of  those  with  marked  nasal 
deformity.  The  n((.s(i!  cavities  serve  the  fin)ct ions  of  olfaction,  and 
respiration  (filtering,  warming  and  moistening  the  air)  and  assist  in 
the  taste  and  voice. 

The  groove  between  the  nose  and  the  cheek  is  a  favorable  site  for 
ineisions,  as  in  excision  of  the  maxilla,  for  the  resulting  scar  is 
scarcely  perceptible.  From  without  inward  we  find  the  following 
layers  composing  the  nose. 


THE  SKIN.  73 

(1)  The  skin  is  tliin  aiul  loosely  adheriiit  over  the  root  and  most  of 
the  dorsum  of  the  nose,  thick  and  closely  hound  to  the  subcutaneous 
tissue  over  the  ahic.  I  Fence  in  plastic  operations  the  skin  readily 
lends  itself  to  the  formation  of  Haps  in  the  former  situation  but  not  in 
the  latter.  The  skin  is  extremely  fa.s-cw/«/' so  that  wounds  and  plastic 
operations  heal  well.  This  vascularity  explains  the  readiness  of  the 
nose  to  assume  a  rosy  color  from  the  dilating  effect  on  the  vessels  of 
heat,  cold,  alcohol,  etc.  The  skin  of  the  lower  part  of  the  nose  is 
furthermore  very  richly  supplied  with  sudoriferous  ixn(\.  f<e/jaceoa.s g/ands 
so  that  it  is  a  favorite  site  for  acne.  The  hypertrophic  form  of  acne 
known  in  this  situation  as  "grog  blossom  "  may  produce  a  red  tuber- 
ous enlargement  of  considerable  size.  From  an  exj)erience  of  several 
cases  I  have  found  that  this  disfigurement  may  be  satisfactorily  treated 
by  shaving  down  and  shaping  the  nose,  taking  care  not  to  cut  through 
the  mucous  membrane,  and  then  skin  grafting  the  surface  or  allowing 
it  to  cicatrize.  Lupus,  lupus  erythematosus  and  epifhelioma  are  fre- 
quently met  with  here.  The  plastic  operations,  or  the  removal  fol- 
lowed by  skin  grafting,  for  epithelioma  give  excellent  results.  Not- 
withstanding the  abundant  blood  supply  the  nose,  like  the  ear,  is  prone 
to  frost  bite  on  account  of  its  exposed  situation  and  the  superficial 
position  of  the  vessels,  the  circulation  of  which  at  the  edge  of  the 
nostril  is  terminal.  The  vascularity  of  the  lower  part  of  the  nose 
favors  congestion,  which  partly  accounts  for  the  pain  in  inflammation 
here.  For,  on  account  of  the  firm  adherence  of  the  skin  and  subcu- 
taneous tissue  and  the  density  of  the  latter  tissue  in  this  part  of  the 
nose,  the  swelling  due  to  congestion  necessitates  pressure  upon  the 
nerves.  These  nerves  are  branches  of  the  first  or  second  divisions  of 
the  fifth  nerve. 

The  next  layer  (2)  the  subcutaneous  tissue  has  already  been  referred 
to.  It  is  loose  above,  dense  below.  The  subjacent  or  fihromuscnlar 
layer  (3)  requires  no  special  notice.  (4)  The  osteocartilaginous  layer 
forms  the  framework  of  the  nose.  This  is  also  supported  by  the  osteo- 
cartilaginous nasal  septum,  the  loss  of  substance  of  which,  especially 
in  its  cartilaginous  j)ortion,  may  affect  the  shape  of  the  nose. 

The  movability  of  the  lower  or  cartilaginous  part  of  the  nose  obvi- 
ates many  fractures.  The  latter  are  most  common  through  the  lower 
and  thinnest  third  of  the  nasal  bones.  In  the  upper  third  fracture  is 
rarest  on  account  of  the  thickness  and  firm  support  of  the  bon(^s,  but 
it  is  here  most  serious,  for  it  rccpiires  considerable  force  and  is  liable 
to  involve  the  vertical  and  cribriform  plates  of  the  ethmoid  and  thus 
cause  an  indirect  fracture  of  the  base  of  the  skull.  The  dix})lacement 
of  bony  fragments  in  a  fracture  of  the  nose,  which  is  due  solely  to  the 
direction  of  the  force,  should  l)e  reduced  by  elevation  from  within  the 
nasal  cavity,  as  by  the  beak  of  a  steel  sound,  combined  with  manipu- 
lation from  without.  Otherwise  defonniti/  results.  rnion  of  the 
fragments  has  been  observed  as  early  as  the  seventh  day  (Hamilton) 
and  it  occurs  more  rapidly  than  with  any  other  fracture.  When  (5) 
the  mucosa  is  torn  through   in  a  fracture,  epistaxus  and   subcutaneous 


74  THE  HEAD  AXD  NECK. 

emphysema  are  likely  to  occur  and  the  latter  is  increased  on  blowing 
the  nose.  The  bony  portion  or  bridge  of  the  nose  is  not  infrequently 
much  depressed.  This  depends  not  so  often  upon  fracture  as  upon 
imperfect  development  from  malnutrition  in  those  with  inherited  syph- 
ilis. The  cartilaginous  part  may  also  be  destroyed  by  the  ulceration 
of  lupus,  syphilis  or  epithelioma. 

The  various  deformities  of  the  nose,  on  account  of  the  hideous  dis- 
figurement often  produced,  have  led  to  numerous  plastic  operations 
[rhinoplasty).  Some  of  these  were  practiced  centuries  ago.  Partial 
rhinoplasty  often  gives  excellent  results.  A  depressed  bridge  of  the  nose 
may  be  improved  by  the  introduction  beneath  the  skin  of  an  aseptic 
substance  to  fill  out  the  depression.  The  difficulty  in  total  rhinoplasty 
is  that  a  nose  made  of  soft  parts  has  no  firm  support  and  is  liable  to 
contraction.  For  this  reason  the  Indian  method,  by  which  the  new 
nose  is  made  of  a  flap  from  the  forehead,  has  been  modified  to  include 
in  the  flap  the  outer  table  of  bone  and  the  flap  is  not  twisted  as  in  the 
Indian  method  but  inverted  and  its  raw  outer  surface  covered  by  skin 
flaps  from  the  sides.  In  cases  where  there  is  an  actual  loss  of  the 
nose  and  not  a  mere  deformity  the  operation  is  advisable. 

The  limits  of  the  cartilaginous  part  should  be  remembered,  for  in  in- 
troducing and  opening  a  nasal  speculum  the  latter  should  not  be  passed 
beyond  those  limits,  otherwise  pain  results.  The  lower  of  the  two 
pairs  of  cartilages  of  the  nose  are  curved  around  in  front  of  the  nostril, 
whose  contour  they  form.  The  mesial  interval  between  their  internal 
branches  can  be  felt  at  the  tip  of  the  nose  and  into  it  projects  the 
septal  cartilage.  The  latter  can  therefore  be  reached  and  resected  by 
a  median  incision  between  the  lateral  cartilages  without  opening  the 
nasal  cavities. 

Several  operations  are  performed  on  the  nose  to  expose  the  nasal 
fossce  or  even  the  nasopharynx  behind.  In  Rouge's  operation  the 
incision  is  made  through  the  mucous  membrane  where  it  is  reflected 
from  the  gums  to  the  upper  lip,  between  the  second  bicuspids  of  both 
sides.  Then  the  soft  parts  which  connect  the  upper  lip  and  nose  to 
the  bone  are  divided  and  the  lip  turned  well  up,  exposing  the  anterior 
part  of  the  nasal  fossse  without  any  incision  of  the  skin.  Or  the  nose 
may  be  turned  down  after  incising  the  soft  ])arts  in  the  groove  on 
either  side  of  it  and  across  its  root  and  dividing  the  bone  in  the  same 
line. 

The  suture  between  the  nasal  and  frontal  bones  at  the  root  of  the 
nose  is  a  favorite  place  for  meningoceles,  etc.  They  have  been  mis- 
taken for  naevi,  being  often  covered  by  a  thin  vascular  skin.  In  rare 
instances  they  escape  through  the  cribriform  plate  into  the  nasal  fossse, 
and  being  mistaken  and  treated  for  a  polypus,  the  cribriform  plate  has 
been  injured  and  fatal  meningitis  resulted. 

The  nasal  fossae  open  in  front  by  the  nostrils  and  communicate  behind 
with  the  naso])harynx  through  the  posterior  nares.  The  nostrils  or 
anterior  nares  look  downward  and  are  at  a  somewhat  lower  level  than 
the  floor  of  the  nasal  fossse.      Hence  in  examining  the  fossse  as  through 


PLATE    IV. 


ENO-PALATINE 
ARTERY 


OPTIC    NERVE 


IN  FRAORBITAL 
NERVL 


INTERNAL 
MAXILLARY 
ARTERY 


DESCENDING 

PALATINE 

ARTERY 


Transverse  vertical  section  of  tlie  nasal  fossse,  viewed 
from  in  front,  showing  the  back  of  the  right  orbit  and  the 
right  antrum  of  Highmore,  with  the  sphenomaxillary  fossa 
behind  the  latter,  exposed  through  an  opening  of  its  pos- 
terior wall.     (Zuckerkandl. ) 


THE  NASAL  FOSS.E.  to 

a  speculum  the  tip  of  the  nose  is  raised  and  the  head  is  thrown  back. 
In  this  manner  the  floor  of  the  nose,  the  lower  part  of  the  septum,  the 
greater  part  of  the  inferif)r  turlMuate  bone  and  the  lower  margin  of  the 
middle  turbinate  bone  may  be  seen,  with  a  good  light.  The  nostrils 
are  separated  by  the  columna,  composed  of  skin  and  fibrous  tissue, 
which  extends  below  the  septal  cartilage  and  the  latter  may  be  reached 
by  splitting  the  columna  mesially. 

The  anterior  nasal  orifice  is  the  heart-shaped  anterior  or  facial  aper- 
ture of  the  bony  nasal  fossie  mecmiring  1]  inches  vertically  and  a  little 
less  transversely,  in  its  widest  part.  It  can  be  palpated  by  the  finger 
introduced  through  the  nostril.  The  portion  of  each  nasal  fossa 
between  the  anterior  nasal  orifice  and  the  nostrils  is  called  the  vestibule 
and  differs  from  the  rest  of  the  fossa  in  being  covered  by  the  cartilagi- 
nous part  of  the  nose  and  in  being  lined  by  a  squamous  epithelium. 
This  is  beset  near  the  nostrils  with  stiff  hairs  which  serve  to  filter  the 
air  and  arrest  particles  of  dust.  It  is  also  provided  with  sebaceous 
glands  and  is  liable  to  eczema  and  to  painful  furuncles  originating  in 
the  glands,  etc. 

The  posterior  nares  are  symmetrically  placed  on  either  side  of  the 
posterior  border  of  the  nasal  septum,  which  forms  their  mesial  boundary. 
They  measure  1  to  1}  inch  vertically  and  one  half  inch  transversely 
in  the  skeleton,  but  these  measurements  are  reduced  somewhat  by  the 
covering  of  mucosa  and,  in  the  upper  and  outer  aspects,  by  the  pro- 
jection of  the  Eustachian  tube.  They  may  be  seen  with  difficulty  by 
posterior  rhinoscojji/,  in  which  a  small  mirror  is  introduced  behind  the 
soft  palate.  Through  this  can  be  seen,  under  favorable  circumstances, 
the  posterior  part  of  the  septum,  the  turbinate  bones  and  meatuses, 
also  the  Eustachian  tubes  and  the  upper  part  of  the  pharynx.  The 
same  parts  may  be  felt  by  the  finger  introduced  through  the  mouth 
and  above  the  soft  palate.  The  posterior  nares  are  sometimes  plugged 
to  arrest  bleeding  from  the  nose.  For  this  purpose  a  pyramidal  plug 
of  several  folds  of  gauze  is  made  whose  base  measures  a  little  more 
than  the  posterior  nares.  This  is  threaded  with  two  ligatures  from 
the  apex  and  one  from  the  base  and  pulled  up  into  place  from  behind 
by  means  of  a  cord  which  has  been  passed  through  the  inferior  meatus 
into  the  pharynx  and  out  through  the  mouth  by  a  Bellocq's  sound  or 
a  soft  catheter.  The  two  cords  pass  out  through  the  nostril  and  are 
there  tied  tightly  over  a  plug  in  the  nostril,  thereby  ])lugging  the  latter 
and  holding  the  posterior  plug  snugly  in  place.  The  single  cord  from 
the  base  of  the  plug  is  passed  out  through  the  mouth  to  be  used  in 
withdrawing  the  plug.  The  same  object  may  usually  be  accomplished 
by  inserting  a  strip  of  gauze  through  the  nostril  and  packing  it  well 
into  the  nasal  fossa\ 

The  nasal  fossae  (Fig.  19)  fie  beneath  the  cranium,  above  the  mouth 
and  between  the  (»rbits  and  maxillary  sinuses.  They  are  very  narrow 
above  but  widen  out  somewhat  below,  so  that  while  there  intervenes  a 
space  of  4  to  o  mm.  between  the  inferior  turi)inate  bone  and  the  septum, 
only  2  mm.  intervenes  between  the  latter  and   the  superior  turbinate 


76  THE  HEAD  AND   NECK. 

bone.  In  fact,  the  latter  space  is  so  narrow  that  surgically  the  supe- 
rior turbinate  bone  practically  forms  the  roof  of  the  nasal  foss?e.  Owing 
to  the  narrowness  of  the  fossa?  polypus  or  other  forceps  are  best  intro- 
duced so  as  to  be  opened  vertically. 

The  floor  is  the  widest  part  of  the  nasal  fossfe  and  measures  at  its 
center,  or  widest  part,  12  to  15  mm.  in  width.  It  is  smooth,  concave 
from  side  and  slanted  slightly  downward  behind,  so  that  in  the  erect 
position  secretions  drain  backward  to  the  pharynx. 

The  roof  is  extremely  narrow,  2  to  3  mra.,  so  that  surgical  explora- 
tion or  operation  here  is  nearly  out  of  the  question  and  there  is  little 
danger  of  its  penetration  by  anything  as  large  as  a  polypus  forceps. 
Yet  it  has  been  perforated  by  slender  bodies,  by  accident  or  design, 
and  the  cranial  cavity  thereby  opened  through  the  cribriform  plate.  In 
such  cases,  or  in  fracture  of  this  plate  involving  the  mucosa  beneath 
it,  there  is  bleeding  from  the  nose,  the  discharge  of  cerebrospinal 
fluid,  if  the  subarachnoid  space  is  opened,  and  the  danger  of  menin- 
gitis, as  it  is  impossible  to  make  and  keep  the  nose  aseptic.  In  fact 
meningitis  has  resulted  from  the  extension  of  inflammation  through  an 
intact  nasal  roof  in  case  of  inflammation  of  the  nose.  In  front  of  the 
cribriform  plate  the  roof  slants  downward.  It  is  here  formed  by  the 
nasal  bones  and  the  nasal  spine  of  the  frontal,  and  above  the  latter  lie 
the  frontal  sinuses.  Behind  the  cribriform  plate  the  roof  slants  more 
abruptly  downward  and  is  formed  by  the  anterior  surface  of  the 
sphenoid  containing  the  openings  of  the  sphenoidal  sinuses.  It  follows 
that  the  hclf/ht  of  the  fossae  is  greatest  about  their  center. 

The  median  wall  or  septum  is  straight  in  children  up  to  the  seventh 
year  but  in  adults  it  devUdes  to  one  side,  in  over  75  percent,  to  the  left. 
A  deviation  may  follow  an  injury  but  this  is  not  the  common  cause. 
The  nose  as  a  whole  is  seldom  absolutely  straight  and  this  has  been 
attributed  to  blowing  the  nose  with  the  same  hand,  usually  the  right, 
sleeping  largely  on  the  right  side,  etc.  The  septal  deviation  involves 
the  bony  and  the  cartilaginous  portions  and  if  it  is  marked  it  may 
more  or  less  block  one  nasal  fossa  by  contact  with  the  turbinate  bodies. 
This  contact  is  a  source  of  constant  irritation  and  may  result  in  fusion 
of  the  parts  (synechia).  Until  we  examine  the  opposite  fossa  and  note 
the  concavity  of  the  septum  we  may  mistake  the  deviation  of  the  sep- 
tum for  a  septal  tumor,  abscess  or  hpematocele  or  even  a  nasal  polyp. 
There  are  many  operations  for  the  restoration  of  the  blocked  fossa  or 
the  straightening  of  the  septum.  Exostoses  or  "  spurn  "  are  liable  to 
grow  on  the  septum,  especially  at  the  junction  of  the  bony  and  carti- 
laginous portions.  As  the  septal  cartilage  is  the  principal  support  of 
the  cartilaginous  part  of  the  nose  its  destruction  by  syphilis  causes  a 
great  flattening  of  this  part  of  the  nose.  Syphilitic  destruction  of  the 
bony  and  cartilaginous  septum  and  of  the  adjacent  bones  may  result 
in  the  flattening  of  the  bony  vault  also. 

The  mucosa  covering  the  Heptnin  is  blended  with  its  periosteal  and 
perichondral  covering  into  a  single  dense  layer,  and  the  layer  thus 
formed  is  loosely  attached  to  and  easily  separated  from  the  septum. 


THE  OUTER    WALL. 


11 


Hence  collectiir.is  of  blood  or  )iiis  may  readily  form  beneath  tlie  muco- 
periosteal  covering  ;  also  by  .stri|)i)ing  up  the  latter  the  septum  may  be 
exposed  and  operated  ujion  without  entering  the  nasal  cavity. 

The  outer  v^all  (Fig.  20)  has  a  general  slant  from  above  downward 
and  outward.  The  anterior  end  of  the  inferior  turbinate  bone  reaches  to 
the  junction  of  the  bony  and  cartilaginiuis  part  of  this  wall  and  within 
about  2  cm.  of  the  nostril.  The  posterior  end  of  this  bone  is  at  the 
posterior  nares,  on  a  level  with  the  opening  of  the  Eustachian  tube. 
The  free  border  of  the  inferior  turbinate  l)one  may  extend  so  far  toward 
the  floor  of  the  nasal  fossa  as  to  interfere  with  the  introduction  of  instru- 


FiG.   20. 


PROBE     P>,s 
SINUS   TH«o;*"0 


^^      OPENINGS    OF    POSTERIOR 
ETHMOIDAL   CELLS 


External  wall  of  right  nasal  fossa,  parts  of  the  turbinates  having  been  cut  away  to  show  the  orifices 
of  the  siiiii-si's  which  open  into  the  meatuses.     (tiiCKUisil,  after  Tkstct.  ) 

ments  along  the  inferior  meatus.  Tiie  latter  is  the  icided  part  of  the 
nasal  fossne,  measuring  about  one  half  inch.  Its  greatest  height  (three 
fourths  inch)  corresponds  to  the  opening  of  the  ndsal  duct,  which  is 
about  1  to  1-|  inches  behind  the  nostril.  This  t)pening  lies  just  beneath 
the  attached  border  of  the  inferior  turbinate  bone  at  the  meeting  of 
its  anterior  fourth,  Avhich  is  slanted  sharply  downward  and  forward, 
and  its  posterior  three  fourths,  which  are  slanted  more  gradually  down- 
ward and  backward  (see  also  ]>,  ().")).  The  sharp  downward  slant  of 
the  anterior  fourth  of  the  inferior  turbinate  bone  renders  the  height  of 
the  inferior  meatus  but  little  in  front  and  less  here  than  it  is  behind. 
Hence  itifipired  air  is  not  so  apt  to  enter  this  meatus,  expired  air  more 
apt  to.     This  tendency  is  increased  by  the  downward  direction  of  the 


78  THE  HEAD  AND  NECK. 

nostrils,  the  consequent  upward  current  of  inspired  air,  the  wide  fun- 
nel-shaped anterior  end  of  the  middle  meatus  (tJieafrii(m)  Sind  the  nar- 
rowed posterior  end  of  this  meatus.  This  explains  the  fact  that  we 
smell  inspired  air,  for  it  passes  through  a  meatus  (middle)  part  of  whose 
walls  is  supplied  by  the  olfactory  nerves,  as  well  as  the  fact  that  we 
do  not  smell  expired  air,  for  it  passes  largely  through  the  inferior 
meatus  which  the  olfactory  nerv^es  do  not  reach.  Also  if  we  wish  to 
smell  an  object  we  dilate  the  nostrils  and  sniff  up  the  air  which  thereby 
is  carried  into  the  upper  olfactory  part  of  the  fossse. 

The  anterior  end  of  the  middle  turbinate  bone  inclines  upward  so 
that  it  reaches  the  level  of  the  inner  canthus  of  the  eye.  This  upward 
incliuation  makes  the  middle  meatus  open  up  widely  in  front  iuto  the 
atrium,  into  which  au  instrument,  introduced  through  the  nostril, 
passes  more  readily  than  into  the  inferior  meatus,  unless  care  is  taken. 
About  the  center  of  the  middle  meatus  is  the  slit-like  opening  of  the 
antrum,  about  one  incli  above  the  floor  of  the  nasal  fossa  and  nearer 
the  roof  than  the  floor  of  the  antrum.  This  opening  is  at  the  lower 
end  of  a  deep  groove,  the  infundibulum,  which  curves  downward  and 
backward,  beneath  the  attached  margin  of  the  superior  turbinate  bone, 
from  the  opening  of  the  canal  leading  from  the  frontal  sinus.  Into 
this  groove  open  also  the  anterior  ethmoid  cells. 

The  mucous  membrane  varies  in  different  parts  of  the  nasal  fos- 
sse.  Behind  the  vestibule  the  nasal  fossa  is  divided  into  an  upper 
olfactory  region  including  the  middle  and  upper  turbinate  bones  and 
the  up})er  third  of  the  septum,  which  is  covered  by  columnar  epithe- 
lium, and  a  lower  respiratory  region  including  the  rest  of  the  fossa, 
which  is  covered  by  columnar,  ciliated  epithelium.  On  the  outer  wall 
between  the  turbinate  bones  and  on  the  floor  the  mucosa  is  thin,  else- 
where it  is  thick  and  vascular,  especially  over  the  turbinate  bones. 
This  thickness  over  the  turbinates  is  largely  due  to  the  abundant  sub- 
mucous venous  j)lexus,  the  meshes  of  which  run  mostly  antero-poste- 
riorly.  The  mucous  membrane  extends  in  a  fold  beyond  the  inferior 
turbinate  bone  in  front,  behind  and  below.  Over  this  bone  the  veins 
of  the  thick  mucosa  form  a  kind  of  cavernous  or  erectile  tissue.  This 
may  swell  up  rapidly  from  engorgement  of  the  veins  so  as  to  come  in 
contact  with  the  septum  and  this  contact  is  in  itself  a  source  of  irri- 
tation. The  rapid  shrinkage  of  this  "erectile  body"  when  a  caustic 
like  chromic  acid  is  applied  to  it  is  very  striking. 

The  acinous  glands  of  the  mucosa,  secreting  for  the  most  part  a 
thin  watery  fluid,  are  most  numerous  over  the  inferior  turbinate  bone 
and  the  middle  and  posterior  parts  of  the  fossae.  They  account  for 
the  profuse  secretion  in  coryza.  The  normal  function  of  this  secretion 
appears  to  be  to  moisten  the  inspired  air,  that  of  the  great  vascularity 
of  the  mucosa  to  warm  ti)e  inspired  air.  Adenoid  tissue  is  abundant 
in  the  mucosa  of  the  posterior  part  and  is  continuous  with  that  of  the 
nasopharynx.  Several  of  the  openings  found  in  the  bony  fossae  are 
closed  by  the  mucosa.  From  the  relations  of  the  nasal  fossae  and  the 
continuity  of  its  mucosa  with  that  of  other  parts  it  follows  that  infkrni- 


THE  NERVE  SUPPLY.  79 

matioii  of  this  mucosa  (coryza)  may  spraul  tliroiitrh  tlie  ])osterior  iiares 
to  the  ])liarynx  and  to  the  Eustachian  tubes,  tliroui^h  the  nasal  duct  to 
the  lachrymal  sac  and  conjunctiva  and  through  the  iniundibulum  to 
the  frontal  and  maxillary  sinuses  and  the  ethmoid  cells.  One  or  more 
of  these  extensions  is  often  exempliiied  in  a  coryza. 

Swollen  turbinate  bones  may  be  mistaken  for  mucous  polypi  whicii 
are  common  in  the  nose  and  usually  arise  from  the  inferior  or  middle 
turbinate  bones.  They  often  grow  in  crops,  block  the  fossae  and  may 
press  upon  and  widen  the  nose  or  obstruct  the  opening  on  its  outer 
wall.  They  may  be  removed  with  the  snare  or  polypus  forceps,  care 
being  taken  not  to  damage  the  cribriform  plate  in  case  of  liigh  attach- 
ment. The  fibrous  and  sarcomatous  polypi  take  origin  as  a  rule  from 
the  periosteum  of  the  roof  of  the  nose  or  piiarynx  and  spread  in  all 
directions. 

The  blood  supply  of  the  nose  is  derived  from  three  sources,  the 
ophthalmic,  facial  and  internal  maxillary.  The  veins,  in  addition  to 
accompanying  the  arteries,  communicate  with  the  superior  longitudinal 
sinus  through  the  foramen  ctecum  in  children  and  sometimes  in  adults. 
This  communication  and  that  with  the  cavernous  sinus  through  the 
ophthalmic  veins  help  to  explain  intracranial  complications  in  some 
cases  of  inflammation  of  the  nasal  cavities. 

Bleeding  from  the  nose,  or  epidaxis,  may  be  due  to  fracture  or  other 
injury,  general  oozing  of  the  vascular  mucosa,  ulceration  or  venous  con- 
gestion, as  in  cardiac  or  pulmonary  disease.  In  the  latter  case  the 
patient  should  be  kept  erect  to  aid  venous  return  and  the  raising  of 
the  arras  is  recommended  on  account  of  the  resulting  expansion  of  the 
thorax  and  its  aspiration  upon  the  cervical  veins.  In  some  cases  the 
bleeding  is  vicarious.  The  tdcerafions  are  apt  to  be  on  the  septum, 
where  they  should  be  sought  for.  Nose  bleed  may  be  profuse  and 
long  continued;  as  much  as  75  lbs.  of  blood  has  been  lost  altogether 
(Frankel),  and  it  has  continued  for  twenty  months  on  and  off  (Spencer 
Watson).  If  it  resists  local  applications  pft>(jf/i)u/  of  the  nares  or  nasal 
fossiB  (p.  7"))  may  have  to  be  employed  to  arrest  a  fatal  result,  which 
has  occasionally  occurred.  The  great  vascularity  of  the  nasal  mucosa 
accounts  for  the  frequent  occurrence  of  epistaxis. 

The  lymphatics  communicate  through  the  cribriform  plate  with  the 
subdural  si)ace  and  also  enter  the  submaxillary,  parotid  and  retro- 
pharyngeal nodes.  Abscess  of  the  last-named  nodes  may  therefore  be 
due  to  disease  of  the  nose,  and  in  lymphadenitis  of  the  cervical  nodes 
we  are  forced  by  exclusion  in  many  cases  to  assume,  if  not  to  prove, 
that  the  source  of  infection  was  in  the  nose  or  naso]iharyux. 

The  nerve  supply,  apart  from  the  olfactory  nerve  whose  distribu- 
tion has  been  given  above,  is  from  the  first  and  second  divisions  of 
the  fifth  iierre.  The  nasa/  bnowh  of  the  opJdhulmie  division  of  the 
fifth  nerve  supjilies  theantero-su})erior  part  of  the  nasal  fossa?  and  ex- 
plains the  following  reflexes  in  connection  with  other  branches  of  this 
division  of  the  nerve ;  i.  e.,  the  kichri/nuition  that  may  follow  a  pun- 
gent odor  and  the  sneezing  from  looking  at  bright  sunlight.      In   tlie 


80  THE  HEAD  AND  NECK. 

former  case  the  irritation  is  referred  to  the  lachrymal  branch  of  the 
same  division  and  in  the  latter  case  it  is  referred  from  the  nerves  of 
the  orbit  to  the  nasal  branch.  Sncczhuj  also  follows  the  direct  irrita- 
tion of  the  nerves  of  the  nose  by  chemical  or  mechanical  irritants  like 
snuff  or  dust  or  the  abnormal  contact  of  the  septum  and  outer  wall  of 
the  nose.  Carious  accidents  have  occurred  during  violent  acts  of 
sneezing.  Thus  Treves  mentions  fracture  of  the  ninth  rib,  disloca- 
tion of  the  shoulder,  and  rupture  of  all  the  coverings  of  a  large  fem- 
oral hernia. 

The  lodgment  of  foreign  bodies  in  the  nose  is  quite  common.  That 
they  may  remain  in  some  cases  for  long  periods  of  time  without  caus- 
ing much  trouble  is  illustrated  by  a  case  reported  by  Tillaux  of  an  old 
woman  from  whose  nose  he  removed  a  cherry  stone  that  had  lodged 
there  for  twenty  years.  When  they  remain  long  they  may  become 
encrusted  by  calcareous  matter  and  thus  form  rhinoliths  which  are  most 
common  in  the  lower  meatus.  In  some  cases  of  chronic  purulent  dis- 
charge from  one  nostril  the  cause  may  be  the  presence  of  a  bean,  bead, 
button  or  other  foreign  body  in  the  nose. 

The  nasal  douche  may  be  used  in  more  than  one  way.  Thus  with 
the  head  lowered  a  little  and  the  mouth  open  the  nozzle  of  the  irriga- 
tor is  introduced  into  one  nostril  and  the  fluid  flows  out  of  the  other 
after  passing  from  one  fossa  to  the  other  behind  the  posterior  nares. 
This  is  possible  from  the  fact  that  in  breathing  through  the  mouth  the 
palate  is  elevated  so  as  to  continue  in  line  with  the  nasal  floor  behind 
the  posterior  nares  and  shut  off  the  nasal  fossa  from  the  pharynx. 
But  at  the  same  time  the  Eustachian  tube  is  opened  by  the  same  mech- 
anism that  raises  the  palate  and  there  is  some  danger  of  infection 
being  carried  into  it.  Again,  with  the  head  tilted  slightly  backward, 
the  douche  may  be  allowed  to  flow  back  until  it  reaches  the  pharynx, 
the  mouth  being  kept  closed. 

The  Accessory  Sinuses  of  the  Nose. 

The  frontal  sinuses  do  not  exist  at  birth  but  their  evolution  occurs 
between  tiie  seventh  and  twenty-first  year.  Tliey  may  be  considered 
as  developed  from  the  diploe  and  hence  lie  between  the  inner  and  outer 
tables  of  the  skull,  or  they  may  be  considered  as  prolongations  of  the 
ethmcjid  cells.  They  are  situated  above  and  external  to  the  nose,  above 
and  internal  to  the  orbits,  and  beneath  and  in  front  of  the  cranial 
cavity.  They  lie  on  either  side  of  the  glabelhi  and  behind  the  .super- 
ciliary ridges  whose  prominence  they  form.  But  the  absence  of  these 
prominences  does  not  necessarily  imply  absence  of  the  sinuses  as  they 
may  extend  backward  only.  The  orbital  and  cranial  walls  of  the 
sinuses  are  formed  by  thin  l>ony  lamella?.  The  sinuses  are  divided  into 
two  lateral  halves  by  a  scptma,  often  incomplete  and  sometimes  want- 
ing, which  is  median  inferiorly  but  deviates  to  one  side  above. 
Sometimes  they  are  so  small  as  to  be  scarcely  noticeable,  at  other 
times  they  may  be  large  enough  to  contain  two  or  more  ounces,  or  to 
contain  a  foreign  body  of  some  size.     In  old  people  these  sinuses  may 


THE  ANTRUM  OF  HIGHMORE.  81 

enlarge  as  the  brain  shrinks.  Well-developed  sinuses  may  extend  2 
inches  upward,  1^  inches  outward  and  nearly  as  far  backward.  In 
injury  to  this  re<^ion  there  may  be  a  depressed  Jrcictare  without  damage 
to  the  cranial  cavity,  in  which  case  air  may  be  forced  through  the 
opening  on  blowing  the  nose  and  cause  frothing  of  the  blood  if  the 
fracture  be  compound,  or  subcutaneous  emphysema  in  a  simple  fracture. 
In  the  adult  therefore  fracture  here  is  less  serious  than  elsewhere  on 
the  skull,  as  the  brain  case  may  be  spared. 

The  frontal  sinuses  are  lined  by  a  pah-,  thin,  loosely  adherent  lan- 
cosa  continuous  with  that  of  the  nose,  through  the  infundibula,  and 
liable  to  extension  of  iaiiammation  from  the  nose.  Hence  the  frontal 
headache  in  some  cases  of  coryza,  ozoena,  etc.  The  mfundibular  pas- 
sage is  d('e|)ly  placed  near  the  inner  wall  of  the  orbit  and  opens  into 
the  infinulibular  groove  about  on  a  line  with  the  tendo  oculi.  By  the 
swelling  of  the  mucosa  of  the  infundibulura  its  lumen  is  tem])orarily 
occluded.  When  pus  forms  we  have  empyema  of  the  frontal  sinus  or 
sinuses.  P^ventually  in  such  cases  the  walls  give  way  at  their  weakest 
point,  which  in  90  per  cent,  of  cases  is  the  orbital  roof,  and  the  abscess 
discharges  through  the  inner  half  of  the  upper  lid.  Occasionally  the 
posterior  wall  of  the  sinus  is  eroded  and  perforated,  giving  rise  to  a 
subdural  abscess  or  pachymeningitis,  or  in  some  cases  meningitis  or 
brain  abscess. 

The  frontal  sinuses  require  openhif/  by  the  chisel,  burr  or  trephine 
in  cases  of  empyema  and  may  be  reached  by  a  vertical  incision  which 
avoids  the  vessels  and  nerves  of  this  region.  This  incision  is  made  in 
the  median  line  to  open  both  sinuses  or  laterally,  cither  internal  or 
external  to  the  supraorbital  notch,  to  open  a  single  sinus.  The  rees- 
tablishment  of  drainage  into  the  nose  is  most  desirable. 

In  some  curious  cases  insects  like  centipedes,  larvfe  and  even  mag- 
gots have  found  their  way  into  the  frontal  sinuses;  in  the  latter  case 
setting  uj)  a  violent  septic  iiiHamniation.  Bony  tumors  may  grow  from 
the  fibrous  hiycr  lining  the  deep  surface  of  the  mucosa. 

The  antrum  of  Hig-hmore  or  maxillary  sinus  (Figs.  16  and  19)  is 
present  at  birth,  but  continues  to  grow  until  old  age  when  its  walls 
become  very  thin.  It  occu])ies  the  body  of  the  maxilla  and  is  ]iyramidal 
in  s/iajjc  with  its  base  internally  toward  the  nasal  fossa.  Its  anterior 
or  facial  wall  is  the  thickest  but  the  most  accessible  so  that  the  upeninc/ 
of  an  empyema  of  the  antrum  is  usually  made  on  this  surface  above  the 
first  or  second  molars,  after  incision  of  the  mucous  membrane  where  it 
is  reflected  from  the  gums  to  the  cheek.  Inflannnation  and  iinjiyema 
of  the  antrum  may  be  due  to  the  diseased  root  of  a  tooth,  especially 
that  of  the  first  and  second  molars.  The  roofs  of  the  latter  teeth  often 
cause  a  prominence  in  the  lower  j>artof  the  antrum  and  may  even  pro- 
ject uncovered  into  it.  In  diseased  conditions  the  sockets  of  almost 
any  of  the  teeth  may  eonnnunicate  with  it.  M'hcn  the  diseasetl  root  of 
a  first  or  second  molar  is  drawn  it  may  open  :uid  drain  the  antrum 
from  its  lowest  ])oint  but  this  method  of  drainage  as  an  operation  of 
choice  has  the  disadvantage  that  it  allows  food  particles  to  enter  the 
6 


82  THE  HEAD   AND   NECK. 

antrum.  Behind  the  antrum  is  the  sphenomaxillary  fossa  (Fig,  19)  con- 
taining Meckel's  ganglion,  to  remove  which  the  route  through  the 
antrum,  after  resecting  its  facial  and  zygomatic  walls,  has  been  tried. 
The  upper  wall  separating  it  from  the  orbit  is  very  thin  so  that  tumors 
of  either  of  these  cavities  readily  extend  into  the  other.  As  this  wall 
contains  the  infraorbital  nerve,  in  a  groove  and  canal,  and  the  anterior 
and  posterior  walls  contain  the  nerves  of  the  upper  teeth,  tumors,  etc., 
which  press  upon  these  walls  are  likely  to  cause  neuralgia  of  the  face 
and  teeth.  The  inner  wall  or  base  corresponds  to  the  outer  wall  of 
the  nose  in  the  inferior  and  middle  meatuses,  in  the  latter  of  which  at 
the  lower  end  of  the  infundibular  groove  is  the  orifice  of  the  antrum. 
As  this  is  above  the  middle  of  the  cavity  it  is  not  arranged  for  drain- 
age. Sometimes,  in  perhaps  10  per  cent,  of  cases,  there  is  another 
opening  a  little  further  back  which  is  pathological  in  many  cases. 
This  wall  is  so  thin  as  to  be  readily  perforated.  The  mucosa  of  the 
nasal  fossa  is  continuous  with  that  of  the  antrum  and  in  this  way 
inflammation  may  extend  from  the  nose  to  the  antrum.  The  mucosa 
of  the  antrum  resembles  that  of  the  frontal  sinus  but  is  somewhat  more 
vascular  and  more  richly  supplied  with  mucous  glands.  The  latter  are 
quite  prone  to  cystic  formation  whereby  the  antrum  may  be  partly  or 
wholly  filled,  a  condition  sometimes  erroneously  called  dropsy  of  the 
antrum. 

Tumors  of  the  upper  jaw  may  originate  in  the  antrum  or  grow  with 
great  rapidity  on  entering  it,  and  in  either  case  they  distend  its  ivalls. 
Thus,  pushing  up  the  roof,  they  invade  the  orbit,  and  breaking 
through  the  thin  inner  wall,  they  obstruct  the  nasal  fossa.  They  also 
protrude  through  the  bottom  of  the  antrum  onto  the  roof  of  the  mouth 
and  form  a  projection  on  the  cheek.  The  only  treatment  for  such 
conditions  is  the  excision  of  the  upper  jaw.  In  one  case  of  fracture 
of  the  anterior  wall  of  the  antrum  under  my  care  emphysema  of  the 
cheek  was  present  and  was  increased  on  blowing  the  nose.  Occasion- 
ally the  antrum  is  subdivided  by  bony  septa  into  recesses  or  separate 
chambers. 

As  to  the  sphenoidal  sinuses  little  need  be  said  except  that  like  the 
other  sinuses  of  the  face  they  serve  the  purpose  of  lightening  the  face 
so  that  in  spite  of  its  growth  the  equilibrium  between  the  anterior 
and  posterior  parts  of  the  head  at  its  articulation  with  the  spine  is  not 
disturbed.  Also,  like  the  maxillary  sinus,  it  may  have  some  effect 
on  the  quality  of  the  voice,  acting  like  a  sounding  box.  Fracture 
through  them  leads  to  bleeding  from  the  nose  and  may  establish  a 
communication  between  the  latter  and  the  cranial  cavity.  Dense  ex- 
ostoses  occur  within  them  as  within  the  frontal  sinuses. 

THE   FACE. 

This  region,  apart  from  the  eyebrows,  eyelids  and  nose,  already 
studied,  and  the  parotid  region  and  lips,  to  be  considered  later,  we  will 
study  layer  by  layer.  The  lower  limit  of  this  region  and  the  boundary 
between  it  and  the  neck  is  the  lower  border  of  the  lower  jaw. 


77//;  SUBCUTAyEOUS  LAYER.  83 

The  skin  of  the  face  is  for  the  most  pari  thin,  line  and  very  vas- 
cular. Its  rdsculariti/  is  seen  in  the  ready  flushing  of  the  cheeks,  in 
bhishintj;  and  fever  ;  in  the  free  bleeding  and  rapid  healing  of  wounds 
or  incisions;  in  the  varicose  or  injected  condition  of  its  fine  vessels  in 
those  exposed  to  cold  and  in  the  subjects  of  alcoholism  and  acne  ;  and 
in  the  common  occurrence  of  nsevi  and  various  forms  of  vascular 
tumors.  As  the  shin  is  richly  supplied  with  sebaceous  and  sweat 
glands  it  is  a  favorite  site  for  acne  and  sef>areoi(,s  cysts.  The  latter 
sometimes  re(j[uire  the  use  of  the  knife  to  avoid  a  more  disfiguring  scar. 
The  skin  of  the  face  is  also  a  favorite  situation  for  the  development  of 
epitheiloiiia  and  lupus.  Over  the  chin,  from  the  median  line  to  the 
posterior  border  of  the  depressor  angularis  muscle,  the  skin  ])artakes 
of  the  character  of  that  of  the  scalp,  or  more  nearly  that  of  the  eye- 
brows, for  instead  of  a  fibroadipose  subcutaneous  layer,  as  in  the  scalp, 
we  have  muscle  fibers  of  several  intersecting  muscles  attached  to  the 
skin  interspersed  with  small  pellets  of  fat.  Here  too  as  in  the  scalp 
the  skin  is  thick  and  dense  and  contains  numerous  hairs  and  seba- 
ceous glands,  and  the  arterioles,  adherent  to  the  parts  through  which 
they  pass,  are  difficult  to  seize  wath  the  artery  clamp.  When  the  skin 
of  this  part  or  that  covering  the  malar  bone  is  struck  by  a  blunt  in- 
strument or  in  a  fall  a  wound  may  be  produced  simulating  an  incised 
wound,  as  is  also  the  case  with  the  scalp. 

The  subcutaneous  layer  is  in  general  lax  so  that  on  the  one  hand 
it  favors  the  spread  of  inflammations,  oedema,  etc.,  and  on  the  other 
hand  it  increases  the  mobility  of  the  skin  and  renders  it  suitable  for 
the  various  plastic  operations  done  here.  In  iwdammation  or  oedema 
the  face  may  be  greatly  sw^ollen  and  in  the  latter  condition  the  swell- 
ing first  appears,  as  a  rule,  in  the  loose  subcutaneous  tissue  of  the 
lower  lid.  The  quantity  of  fat  in  the  subcutaneous  tissue  varies  in 
different  parts  and  under  varying  circumstances.  Thus  it  is  espe- 
cially abundant  in  the  cheeks,  or  those  lateral  regions  corresponding  to 
the  area  lined  by  the  mucous  membrane  on  the  inner  surface.  It  is 
firmer  and  more  abundant  in  children  and  well  nourished  persons, 
more  scanty  in  old  age  and  after  wasting  diseases,  as  indicated  by 
hollow  cheeks  and  prominent  cheek  bones.  Fatty  tumors  are  exceed- 
ingly rare  here. 

In  this  layer  lie  the  main  blood  vessels  of  the  face,  the  principal 
branches  of  the  facial  nerve,  (in  front  of  the  anterior  border  of  the 
masseter),  a  lyuiph  node  near  the  lower  border  of  the  mandible  and  the 
facial  muscles  of  expression.  The  facial  artery,  where  it  crosses  the 
lower  border  of  the  mandible  at  the  antero-inferior  angle  of  the  mas- 
seter, lies  just  anterior  to  its  vein  and  is  covered  by  the  skin  and 
platysma  only.  Here  its  pulsations  can  be  easily  felt  and  it  can  be 
readily  compressed  against  the  bone  or  ligated.  In  passing  towards 
the  angle  of  the  mouth  and  the  ala  of  the  nose  and  thence  up  beneath 
the  nasofacial  groove  it  describes  the  arc  of  a  curve  whose  cord  is 
formed  by  the  straightor  and  more  superficial  facial  vein.  The  free 
communication  of  the   latter   with   the   cavernous  sinus   througii   the 


84  THE  HEAD  AND  NECK. 

ophthalmic  vein  explains  the  danger  of  intracranial  complications  like 
sinus-thrombosis,  in  case  of  septic  processes  of  the  face,  such  as  car- 
buncle, erysipelas,  malignant  pustule,  etc.,  especially  when  they  occur 
near  the  course  of  the  facial  vein,  along  which  they  may  spread  as  a 
phlebitis  or  periphlebitis. 

MaUgnant  pustule,  a  disease  transmitted  from  cattle,  attacks  the  face, 
on  account  of  its  free  exposure,  more  often  than  any  other  part  (even 
the  hands).  Also  in  the  young  a  form  of  gangrene,  cancrum  oris,  some- 
times attacks  and  extensively  destroys  the  soft  parts  of  the  cheek  to 
such  an  extent  that  in  some  cases  the  jaws  may  be  firmly  closed  by  the 
contraction  of  the  resulting  scar.  Owing  to  the  free  blood  supply  ex- 
tensive flaps  in  ])lastic  operations,  or  even  those  torn  up  in  lacerated 
wounds,  keep  their  vitality  in  a  very  remarkable  manner.  As  the 
anastomosis  is  very  free  between  the  two  sides  of  the  foce  or  two  ad- 
joining l)ranches  of  the  artery  both  ends  of  a  divided  facial  artery  must 
be  sought  and  tied  to  check  bleeding.  The  lymph  node  near  the  vessels 
as  they  cross  the  border  of  the  mandible,  is  often  enlarged  in  cases  of 
alveolar  periostitis,  etc.,  from  dental  caries.  Abscess  in  this  region 
not  infrequently  originates  in  this  way. 

The  Nerves. — The  branches  of  the  facial  nerve  are  nearly  hori- 
zontal in  direction.  They  anastomose  and  form  plexuses  with  the  in- 
fraorbital, mental  and  buccal  branches  of  the  fifth  nerve.  The  facial 
nerve  supplies  the  muscles  of  expression,  hence  in  facial  paralysis  there 
is  a  lack  of  expression  on  the  side  ])aralyzed,  the  lines  of  the  face  are 
flattened  out  and  the  surface  is  smoother  than  normal.  The  cause  of 
the  paralysis  may  be  within  the  brain,  in  the  passage  of  the  nerve 
through  the  skull,  in  the  aqueduct  of  Fallopius,  or  external  to  the 
skull.  The  si/mptoms  help  us  to  determine  the  position  of  the  lesion 
according  as  one  or  another  branch,  given  oif  along  its  course,  is 
affected  or  not.  Thus,  if  the  palate  can  not  be  elevated  or  shortened 
on  the  side  paralyzed,  the  lesion  is  thought  to  be  internal  to  the  genic- 
ulate ganglion  from  which  the  great  superficial  petrosal  nerve  passes 
to  Meckel's  ganglion  and,  according  to  many,  from  thence  by  pala- 
tine branches  to  the  levator  palati  and  azygos  uvula?  muscles.  On 
the  contrary,  if  these  muscles  act  the  lesion  is  thought  to  be  distal 
to  the  geniculate  ganglion.  Again,  if  the  taste  is  lost  on  one  side  of 
the  front  of  the  tongue  the  lesion  is  ])roximal  to,  if  it  is  not  lost  it  is 
distal  to,  the  origin  and  giving  off  of  the  chorda  ti/mpani  branch  in 
the  lower  part  of  the  Falh)pian  aqueduct,  for  this  branch  conveys  taste 
fibers  from  the  glossopiiaryngeal  nucleus  to  the  tongue.  Just  below 
the  aqueduct  there  is  given  off  the  posterior  anric}dar  branch  which 
supplies  the  posterior  belly  of  the  occipitofrontalis  and  the  retrahens 
and  attollens  aurem  so  that  these  muscles  are  paralyzed  if  the  lesion  is 
proximal  to  this  branch  but  not  if  it  is  distal  to  it,  and  so  on. 

As  the  orbicularis  palpebrarum,  frontaHi<  and  corrugator  supei^dlii 
muscles  are  not  involved  in  facial  jiaralysis  due  to  a  lesion  of  the 
cortical  facial  center,  it  is  probable  that  the  fibers  which  supply  them 
reach  the  facial  nerve  from  the  oculomotor  nucleus.     Also  the  involve- 


MECKEL'S  GANGLION.  85 

meat  of  the  orbicularis  oris  iu  bulbar  paralysis  and  the  close  associa- 
tion of  the  movements  of  the  lips  and  tongue  suggest  that  tiiis  muscle 
is  supplied  from  the  /if/pof/fossrff  nucleus  through  the  facial. 

The  cliiej  features  of  facial  paralysis  are  the  inability  to  wink  or 
close  the  eye,  so  that  the  cornea  is  always  exposed,  the  dripping  of 
tears  over  the  cheek  (see  p.  63),  a  flabby  cheek  between  which  and 
the  gums  food  lodges,  the  inability  to  whistle  or  pucker  the  mouth 
and  an  expressionless  corner  of  the  mouth,  with  or  without  partial 
loss  of  taste  and  paralysis  of  the  palate  muscles.  Elrctrieitij  can  be 
applied  to  the  nerve  or  its  branches ;  to  the  undivided  trunk  by  an 
electrode  pressed  as  deeply  as  possible  between  the  mastoid  process  and 
the  cartilaginous  auditory  meatus. 

Below  its  exit  from  the  stylomastoid  foramen  the  facial  nerve  is 
accessible  to  surgical  procedure  through  a  curved  incision  in  front  of 
the  mastoid  process  and  the  sternomastoid  muscle.  The  latter  is 
retracted  backward  and  the  parotid  gland  forward,  and  by  blunt  dis- 
section the  styloid  process  is  reached,  behind  which  tiie  nerve  emerges. 

Though  the  main  trunks  of  the  sensory  nerves  belong  to  the  deepest 
layer  of  the  face  their  filaments  pass  through  the  subcutaneous  layer 
to  reach  the  skin.  To  complete  the  study  of  the  nerves  of  the  face 
they  are  best  considered  here.  They  are  branches  of  the  fifth  nerve 
and  three  such  branches  concern  the  region  under  consideration.  The 
infraorbital  branch  of  the  maxillary  (second)  division  of  the  fifth  nerve, 
after  passing  along  a  groove  and  then  a  canal  in  the  floor  of  the  orbit 
(and  the  roof  of  the  antrum),  emerges  on  the  face  at  the  infraorbital 
foramen.  This  is  situated  at  the  nj^per  end  of  the  canine  fossa,  one 
third  of  an  inch  below  the  inferior  margin  of  the  orbit,  near  the  junc- 
tion of  its  middle  and  inner  thirds  and  in  a  vertical  line  from  the 
interval  between  the  two  upper  bicuspids  or  from  the  second  bicuspid. 
When,  as  sometimes  occurs,  it  is  the  seat  of  an  obstinate  neuralgia  it 
may  be  reached  and  resected  either  by  incising  the  mucous  membrane 
above  the  bicuspids  and  separating  the  soft  parts  from  the  bone,  or  by 
a  curved  or  angular  cutaneous  incision  below  the  orbit.  By  lifting  up 
the  contents  of  the  or])it  from  its  floor  the  nerve  is  exposed  in  the  bony 
groove  in  which  it  lies  and  that  part  of  it  may  be  resected  which  lies 
between  the  groove  and  the  foramen.  The  small  arterial  branch 
accompanying  the  infraorbital  nerve  may  usually  be  disregarded. 

Meckel's  ganglion  has  often  been  resected  ibr  certain  neuralgias  of 
the  second  tlivision  of  the  fifth  nerve  by  following  the  infVaorl)ital 
nerve  backward.  Thus,  after  incixiiu/  through  the  lip  and  along  the 
nasolabial  and  nasofacial  grooves,  a  flap  of  skin  is  turned  up  and  the 
anterior  wall  of  the  antrum  <)])oned,  ujt  to  the  infraorbital  foramen. 
The  bony  canal  and  groove  of  the  nerve  is  then  laid  open  from  beneath 
and,  following  the  nerve,  the  posterior  wall  of  the  antrum  is  trephined, 
opening  into  the  sphenoniaxillarj/  fossct.  (Fig.  17.)  This  exposes  the 
triangular  reddish  ganglion  one  fifth  of  an  inch  in  diameter,  lying 
below  the  main  nerve.  The  terminal  branches  of  the  internal  maxillary 
artery  are    in  close  relation  to  the  ga!iglion.      External   to  it   is   the 


86  THE  HEAD  AND   NECK. 

external  pterygoid  muscle,  internal  to  it  the  vertical  plate  of  the  palate 
bone  and  the  sphenopalatine  foramen.  Behind  the  ganglion  the  nerve 
trunk  can  be  followed  back  to  the  foramen  rotundum. 

The  mental  branch  of  the  inferior  dental  trunk  of  the  mandibular 
division  of  the  fifth  nerve  emerges  at  the  mental  foramen,  below  the 
interval  between  the  two  lower  bicuspids  or  below  the  second  bicuspid. 
It  is  thus  seen  to  lie  in  the  same  vertical  line  with  the  infraorbital 
foramen  and  if  this  line  is  continued  upward  it  strikes  the  supraorbital 
notch  or  foramen.  Hence  these  three  branches  of  the  three  divisions 
of  the  fifth  nerve  emerge  through  bony  openings  in  the  same  vertical 
line.  The  mental  foramen  in  the  adult  is  midway  between  the  lower 
and  the  alveolar  borders  of  the  jaw,  in  the  aged  near  the  latter,  in  the 
infant  near  the  former.  It  may  be  exposed  by  a  cutaneous  incision  or 
by  one  through  the  gingivolabial  fold  of  mucous  membrane,  remem- 
bering that  the  foramen  lies  one  third  of  an  inch  below  this  fold. 

The  main  trunk  of  this  nerve,  the  inferior  dental,  may  be  exposed 
for  exsection  at  its  entry  into  the  inferior  dental  foramen  in  one  of 
several  ways.  The  foramen,  it  should  be  remembered,  is  about  equi- 
distant from  all  four  borders  of  the  ramus,  that  is  about  the  center  of 
the  inner  surface.  Surmounting  the  foramen  in  front  is  the  mandibu- 
lar spine  to  be  used  as  a  landmark  when  we  expose  the  nerve  at  its 
entrance  into  the  foramen.  This  is  done  from  within  the  mouth  by 
incising  the  mucous  membrane  from  the  last  upper  molar  to  the  inner 
side  of  the  coronoid  process,  thus  exposing  the  tendon  of  the  temporal 
muscle.  The  finger  is  then  introduced  backwards  between  the  ramus 
of  the  jaw  and  the  internal  pterygoid  muscle  till  the  mandibular  spine 
is  felt.  Thereupon  the  nerve  is  hooked  forward  by  a  blunt  hook,  iso- 
lated from  its  accompanying  vessels  and  divided,  or  a  piece  cut  out  of  it. 

From  the  outside  we  may  expose  the  nerve  by  an  angular  incision 
of  3  cm.  upward  and  5  cm.  forward  from  the  angle  of  the  jaw.  The 
periosteum  of  the  borders  of  the  ramus  is  divided  to  the  same  extent 
and  then  stripped  up  from  the  inner  surface  until  the  mandibular 
spine  is  reached.  Again  it  may  be  exposed  l)y  resection  of  the  angle  or 
posterior  border  of  the  ramus  of  the  jaw,  or  by  a  vertical  incision  over 
the  middle  of  the  ramus,  retracting  Stenson's  duct  upward,  separating 
the  fibers  of  the  masseter,  dividing  the  periosteum  in  the  same  line 
and  trephining  or  chiselling  through  the  center  of  the  ramus.  In  all 
external  vertical  incisions  great  care  must  be  taken  to  avoid  Stenson's 
duct  and  the  facial  nerve. 

The  buccal  nerve  (Fig.  21)  is  another  sensory  branch  of  the  fifth 
nerve,  sometimes  aifected  by  neuralgia  which  is  felt  in  the  skin  and 
mucosa  of  the  cheek  and  lips.  It  may  be  exposed  from  within  or 
without  the  mouth.  As  the  nerve  courses  forwards  on  the  inner  sur- 
face of  the  temporal  muscle,  near  its  insertion  on  the  coronoid  process, 
it  is  only  covered  by  the  mucous  meml)rane,  buccinator  muscle  and 
fatty  tissue,  so  that  it  may  be  exposed  by  dividing  the  latter  layers 
vertically  behind  the  last  molar.  From  the  outside  it  may  be  exposed  by  a 
transverse  incision  of  5  cm.  over  the  course  of  Stenson's  duct  (see  p.  87). 


PLATE  V. 


FIG.  21. 


TEM  PORAL 
MUSCLE 


BUCCAL  NERVE 
EXTERNAL  PTERYGO 
MUSCLE 
MASSETER  MUSCLE 
INFERIOR  DENTAL 
NERVE 
BUCCINATOR  MUSCLE 
LINGUAL  NERVE 


Zygomatic  fossa  and  adjacent  parts  as  seen 
when  exposed  from  the  vestibule  of  the  mouih. 
(Zuckerkandl. ) 


STENSON'S  DUCT.  87 

Stenson's  duct  and  accompanying  nerves  are  retracted  npward  or 
downward,  the  fatty  tissue  (Biciiat's  lobule)  between  tlie  buccinator 
and  masseter  is  removed  or  retracted  and  the  nerve  is  seized  opposite 
the  insertion  of  the  temporal  muscle,  about  2^  cm.  behind  the  ante- 
rior border  of  the  masseter. 

In  this  or  anv  operation  on  the  face  transverse  incisions  are  preferable 
and  vertical  incisions  objectionable  because  of  the  danger  of  wound- 
ing important  structures  having  a  transverse  course.  These  are  the 
branches  of  the  facial  nerve,  already  mentioned,  and  the  duct  of  Sten- 
son  whose  course  is  given  below.  This,  the  excretory  duct  of  the 
parotid  gland  is  beneath  the  deep  fascia,  -which  forms  the  next  of  the 
several  layers  of  this  region.  This  fascia  is  continued  forward  from 
the  parotid  gland,  of  which  it  forms  the  sheath.  The  two  layers  of 
the  parotid  sheath  unite  and  form  the  fascial  covering  of  the  masseter 
and,  in  front  of  this,  of  the  buccinator.  Beneath  the  masseteric  fascia 
lie  the  branches  of  the  facial  nerve  which  (except  the  buccal  branches) 
pierce  it  at  the  anterior  border  of  the  muscle. 

Stenson's  duct,  one  eighth  of  an  inch  in  diameter,  extends  forward 
for  2  to  2?,  inches  from  the  anterior  border  of  the  parotid  gland  to  the 
opening  of  the  duct  on  the  buccal  mucosa,  opjjosife  the  crown  of  the 
second  molar,  4  mm.  below  the  reflection  of  the  mucosa  from  the 
gums  to  the  cheek  and  about  33  mm.  behind  the  angle  of  the  mouth. 
The  course  of  the  duct  is  a  finger's  breadth  or  three  quarters  of  an 
inch  below  the  zygoma  or  in  a  line  from  the  tragus  of  the  ear  to  the  mid- 
point of  the  upper  lip.  The  posterior  or  masseteric  portion  crosses  the 
middle  of  the  masseter,  having  the  socia  pjarotidis  above  or  superficial 
to  it,  the  transverse  facial  artery  above  it,  and  the  buccal  branch  of  the 
facial  nerve  below  it.  It  then  bends  sharply  inward  through  the  fat 
of  the  cheek  to  the  buccinator  muscle  through  which  the  anterior  or 
buccal  portion  runs  obliquely  forward  and  then  for  a  short  distance 
between  the  muscle  and  the  lining  mucosa  to  its  termination. 

The  bends  in  its  course  should  be  remembered,  for  in  passing  a  probe 
through  it  they  should  be  straightened  out  by  pulling  forward  the 
angle  of  the  mouth.  The  course  of  the  duct  should  be  particularly 
remembered  so  as  to  avoid  it  in  any  incision  in  the  cheek,  for  its  divi- 
sion may  be  followed  by  an  obstinate  salivary  fistula.  This  is  particu- 
larly troublesome  in  the  posterior  or  masseteric  portion  where  the  only 
successful  conservative  treatment  is  an  anastomosis  between  the  divided 
ends,  a  difficult  matter  on  account  of  its  small  size.  In  the  anterior 
or  buccal  portion  of  the  duct  a  salivary  fistula  may  be  successfully 
treated  by  stitching  the  proximal  end  of  the  duct  into  an  ojiening  in 
the  buccal  mucosa,  made  by  incising  through  the  buccinator,  behind  its 
normal  opening. 

The  duct  is  surrounded  by  a  fibrous  sheath  continued  forward  from 
the  jiarotid  sheath  and  by  a  fibrous  sheath  of  its  own.  ]^oth  of  these 
sheaths  leave  it  where  it  penetrates  the  buccinator  and  there  become 
continuous  with  the  fascial  covering  of  this  muscle.  Jujiatamation 
may  travel  back  along  the  duct  from  the  buccal  cavity  to  the  gland, 


88  THE  HEAD  AND  NECK. 

in  case  of  stomatitis  in  the  former.  It  is  not  unlikely  that  this  is  the 
route  of  infection  in  some  cases  of  acute  parotitis  complicating  acute 
infectious  diseases.  Hence  the  importance  of  antiseptic  mouth  washes 
in  these  conditions. 

Between  the  buccinator  and  its  fascia  and  behind  Stenson's  duct  is 
a  group  of  deep  buccal  or  molar  glands  which  may  be  the  origin  of 
cysts  or  adenoma.  They  are  opposite  the  last  two  molars.  Behind 
these  and  filling  the  space  between  the  buccinator  and  the  masseter  is 
2k  pad  of  fat,  the  buccal  fat  pad  or  ^'  Bichat's  lobule."  This  is  quite 
constant,  even  in  emaciated  conditions,  but  if  it  be  absorbed  in  wast- 
ing diseases  a  marked  hollow  of  the  cheek  is  produced  in  front  of 
the  masseter.  A  swelling,  from  lipoma  or  ah.sce.Hs  in  this  situation, 
points  in  the  mouth,  as  it  is  beneath  the  buccal  fascia.  In  case  of 
abscess  it  is  to  be  noticed  that  this  fat  is  continuous  with  the  fat  and 
loose  areolar  tissue  in  the  temporal  and  zygomatic  fossse  and  that  which 
covers  the  upper  part  of  the  pharynx.  The  mucous  inembrane  lining 
the  buccinator  is  thin  and  directly  adherent  to  the  muscle  without  sub- 
mucous tissue  between. 

The  Parotid  Region. 

This  is  bounded  superficially  in  front  by  the  posterior  border  of  the 
mandible;  behind  by  tlie  mastoid  process  and  sternomastoid  muscle; 
above  by  the  auditory  meatus,  the  condyle  of  the  jaw  and  the  posterior 
part  of  the  zygoma  ;  below  by  a  line  from  the  angle  of  the  jaw  to  the 
sternomastoid  muscle,  outlined  by  a  thickened  band  of  the  cervical 
fascia.  The  surgical  anatomy  of  this  region  is  most  important  on 
account  of  the  important  parts  in  relation  or  contiguity  with  the  paro- 
tid gland  which  occupies  it. 

This  gland  is  lodr/ed  in  a  narrow  and  deep  but  well-defined  space,  the 
parotid  compartment,  which  is  bounded  as  follows  :  behind  by  tlie  sterno- 
mastoid, the  posterior  belly  of  the  digastric  and  the  mastoid  process; 
in  front  by  the  posterior  border  of  the  ramus  of  the  jaw,  covered  by 
the  masseter  and  internal  pterygoid  muscles ;  above  by  the  external 
auditory  meatus  and  the  posterior  part  of  the  glenoid  fossa  ;  beloia  by 
the  stylomaxillary  ligament  which  separates  the  parotid  from  the 
posterior  end  of  the  submaxillary  gland  ;  internally  by  the  styloid 
process  and  its  muscles,  which  separate  it  from  the  internal  carotid 
and  internal  jugular,  with  their  accompanying  nerves,  and,  in  front  of 
these,  from  the  loose  tissue  around  the  pharynx.  Internal  to  the 
parotid  si)ace  and  in  front  of  and  below  the  tip  of  the  mastoid  may  be 
felt  the  transverse  process  of  the  atlas,  covered  in  part  perhaps  by  the 
posterior  belly  of  the  digastric. 

Within  these  limits  the  i)arotid  is  enclosed  within  a  distinct  sheath 
which  is  derived  from  the  deep  cervical  fascia.  At  the  anterior  border 
of  the  sternomastoid  the  fascia  which  has  formed  the  sheath  of  the 
muscle,  divides  into  two  layers,  one  of  which  passes  internal  and  the 
other  external  to  the  gland.  These  layers  unite  in  front  of  the  gland 
to  become  continuous  with  the  fascia  covering  the  masseter  ;  and  below 
the  gland  they  unite  along   the  thickened   band   between  the  angle  of 


PLATE   VI 


FACIAL 
NERVE 
PAROTID 
APONEU- 
ROSIS, 
SUPERFIC 
LAYER 


FIG.    22. 


RO- 
LLARY 


LOID 
OCESS 
D    ITS 

USCLES 


Horizontal  section  through  the  left  parotid 
connpartment.  Diagrammatic.  Arrow  indicates 
the  pliaryngeal  opening  of  the  compartment. 
(Testui. ) 


FIG.  23. 


EXT.    AUDITORY 
CANAL 


)"'„„.  \  STYLOID 
PROCESS 


PAROTID 

APON  EU- 

ROSIS, 

SUPERFIC. 

LAYER 


Frontal  section  through  the  right  parotid 
compartment  to  show  its  relations.  Dia- 
grammatic. Arrow  indicates  the  pharyn- 
geal opening  of  the  compartment.     (Testui.) 


THE  PAROTID  REGION.  89 

the  jaw  and  the  sternomastoid  muscle.  From  tliis  hand  the  inner 
layer  passes  inward  and  upward  on  the  outer  aspect  of  the  styloid  proc- 
ess and  its  muscles,  forming  the  sheath  of  these  muscles  and  l)ecoming 
attached  to  the  styloid  process. 

Interna/ It/  the  parotid  sJiedi/i  is  (Icficicnt  in  front  of  the  styloid  proc- 
ess, between  it  and  the  internal  pterygoid  muscle,  where  an  uncovered 
prolongation  of  the  gland  projects  inward  into  relationship  with  the 
pharyngeal  wall  in  front  of  the  great  vessels,  etc.  Plence  r/iwc.s.s  or 
tumors  of  the  parotid  are  unopposed  by  the  slieath  in  spreading  inward 
toward  the  pharynx.  Conversely  in  postpharyngeal  abscesses  tiiere 
is  often  a  parotid  swelling  and  sometimes  the  abscess  evacuates  through 
the  parotid.  Anteriorly  there  is  a  process  of  the  gland,  socia  parotidis, 
prolonged  forward  a  variable  distance  on  the  surface  of  the  masscter, 
above  or  overlying  Stenson's  chict,  and,  like  tlie  latter,  covered  by  a 
prolongation  of  the  parotid  sheath.  In  inflammation  or  tumor  of  the 
parotid  therefore  the  swelling  may  extend  forward  onto  the  surface 
of  the  masseter.  Superior/ 1/  the  sheath  is  incomplete,  being  attached 
externally  to  the  inferior  border  of  the  zygomatic  areh  and  the  outer 
part  of  the  cartilaginous  auditory  meatus,  internally  to  the  base  of  the 
styloid  process,  the  free  border  of  the  vaginal  process  and  the  Glaserian 
fissure.  Hence  between  the  outer  and  inner  layers  of  the  sheath 
superiorly  tlie  gland  is  in  direct  contact,  without  intervening  fascia, 
with  the  external  auditory  meatus  and  the  posterior  part  of  the  glenoid 
fossa.  This  accounts  for  the  ease  with  which  i)ijiamiacdions  of  the 
parotid  extend  to  the  external  auditory  meatus  or  the  periosteum  of  the 
adjacent  bones  (see  also  pp.  49  and  50). 

As  a  portion  of  the  gland  occupies  the  posterior  part  of  the  glenoid 
fossa  it  comes  in  direct  relation  with  the  capsule  of  the  temporomandib- 
nlar  joiid  and  explains  in  part  the  pcdn  of  moving  the  jaw  in  cases  of 
parotid  inflammation,  like  mumps,  abscess,  etc.,  and  the  occasional 
extension  of  inflammation  of  the  gland  to  the  joint.  The  pain  is  also 
accounted  for  by  the  fact  that  the  anterior  limit  of  the  parotid  com- 
partment is  formed  by  the  movable  ramus  of  the  jaw  and  the  masseter 
and  internal  pterygoid  muscles  covering  it,  so  that  in  movements  of 
the  jaw,  like  retraction  or  ojiening,  the  space  is  encroached  u})on  and 
the  gland  pressed  upon  by  the  ranuis  or  its  angle  and  the  pain  of  an 
inflamed  parotid  is  aggravated. 

The  fact  that  the  .s/ze  of  the  parotid  compartment,  and  especially  that 
of  its  superficial  boundaries,  is  (dtered  by  the  position  of  the  jaw, 
which  occui)ies  a  groove  on  its  anterior  surface,  should  also  be  remem- 
bered in  operations  on  this  narrow  region  in  which  we  need  all  the 
space  available.  Thus  it  may  be  /xcrcfr.sYY/ antero-posteriorly  by  about 
tluve  eighths  of  an  inch  by  a  simple  protrusion  of  the  jaw  and  to  a 
certain  extent  by  extension  of  tiie  head  whereby  the  sternomastoid  is 
separated  from  the  ramus.  It  is  uarnnred  in  the  opposite  movements. 
In  opening  the  mouth  it  is  narrowed  inferiorly  but  widened  superiorly 
by  the  gliding  forward  of  the  condyle.  The  obliquity  of  the  ramus  in 
infancy  and  old  age  widens  the  lower  part  of  the  space. 


90  THE  HEAD  AND  NECK. 

The  strength  of  the  fascia  superficial  to  the  parotid  offers  much  re- 
sistance to  the  spontaneous  opening  of  a  parotid  abscess  in  this  direc- 
tion. In  addition  to  the  directions  indicated  above  an  abscess  may 
also  extend  downward  to  the  neck,  upward  into  the  temporal  fossa,  or 
forward  toward  the  buccal  cavity,  internal  to  the  ramus  where  the 
sheath  is  weaker  and  is  penetrated  by  the  carotid.  Pus  within  the 
gland  may  also  occasionally  escape  along  a  vessel  or  nerve  where  it 
perforates  the  investing  fascia. 

From  the  inner  surface  of  the  enveloping  fascial  sheath  fibrous  proc- 
esses extending  inward  divide  the  gland  into  lobules  and  support  the 
vessels  and  nerves  which  pass  through  it  or  supply  it.  To  these 
trabecuke  the  vessels  adhere  so  intimately  that  it  is  practically  impos- 
sible to  remove  the  gland  and  spare  the  vessels.  Although  the  7ierve 
trunks  are  less  intimately  adherent,  yet  in  the  living  subject,  especially 
where  the  entire  gland  is  occupied  by  a  tumor,  it  is  impracticable  if 
not  impossible  to  remov^e  the  gland  and  spare  the  nerves  also.  This 
fibrous  framework  is  the  seat  of  the  inflammation  in  the  specific 
parotitis  known  as  mumps.  Acute  parotitis  also  occurs  as  a  compli- 
cation in  septic  or  pyaemic  conditions  ;  during  acute  infectious  diseases, 
such  as  typhoid  fever  and  more  rarely  pneumonia,  and  after  injuries 
and  diseases  of  the  abdomen  and  pelvis.  Abscess  formation  is  to  be 
expected  in  such  conditions  and  the  pressure  on  the  small  vessels  may 
occlude  them  and  cause  a  necrosis  of  the  lobules  of  the  gland  supplied 
by  them. 

Contained  within  and  passing  through  the  gland  are  many  important 
structures.  The  facial  nerve  passes  forward  through  the  gland  from 
the  postero-internal  aspect  with  an  inclination  outward  and  slightly 
downward.  Its  entry  into  the  parotid  corresponds  to  the  point  where 
the  anterior  border  of  the  mastoid  meets  the  external  auditory  meatus. 
It  ^/e.9  superficial  to  the  main  arterial  and  venous  trunks  and  breaks 
up,  after  an  undivided  course  of  about  2  cm.  into  a  plexus  which 
emerges  at  the  anterior  border  of  the  gland,  after  being  joined  by 
branches  of  the  auriculotemporal  nerve.  The  latter  sensory  branch 
of  the  inferior  maxillary  division  of  the  fifth  nerve  passes  from  within 
upward  and  outward  through  the  upper  part  of  the  gland  to  emerge 
at  its  upper  border.  Thence  it  crosses  the  root  of  the  zygoma  be- 
tween the  ear  and  the  temporal  artery  where  it  may  be  exposed  and 
resected.  The  pain  of  a  parotitis  and  of  some  parotid  tumors  may  be 
referred  along  the  course  of  tiie  auriculotemporal  nerve.  The  pres- 
ence of  the  latter  and  of  the  great  auricular  nerve,  supplying  the 
gland  with  sensation,  within  the  unyielding  parotid  fascia  accounts  for 
the  severity  of  this  pain. 

The  external  carotid  artery  lies  undercover  of  the  ramus  of  the  jaw 
up  to  the  junction  of  the  middle  and  lower  thirds  of  its  posterior  border 
where  it  enters  the  internal  or  deep  surface  of  the  parotid  quite  ante- 
riorly. Thence  it  continues  through  the  upper  three  fourths  of  the 
gland  in  a  direction  upward,  outward  and  slightly  backward  to  behind 
the  neck  of  the  condyle  of  the  jaw,  where  it  has  become  more  super- 


THE  PAROTID  REGION.  91 

ficial  and  divides  into  its  two  terminal  branches.  These  (jranche^, 
together  with  the  posterior  auricular  and  sometimes  the  occipital,  are 
within  the  parotid  at  their  commencement.  Within  the  gland  the 
artery  is  aeparated  from  the  interna/  carotid,  and  the  accompanying 
internal  jugular  vein,  vagus,  glossopharyngeal,  hypogastric  and  sym- 
pathetic nerves,  by  the  styloid  process  and  its  muscles,  the  parotid 
fascia  and  a  varying  thickness  of  gland  tissue. 

It  may  be  difficult  at  times  to  tell  the  source  of  arterial  hemorrhage  in 
a  deep  parotid  wound.  But  in  general,  if  the  source  of  the  bleeding 
can  not  be  found  and  both  ends  tied,  it  is  best  to  expose  and  tie  the 
external  carotid  first  and  then  if  necessary  the  internal  carotid,  not  the 
common  carotid.  It  is  evident  from  its  relations  that  the  styloid  proc- 
ess is  a  most  important  landmarh  in  extensive  operations  on  the  parotid 
for  it  indicates  its  inner  boundary,  the  position  of  its  prolongation 
toward  the  pharynx  and  of  the  deep  vessels. 

The  temporomaxillary  vein  lies  superficial  to  the  artery  and  usually 
divides  within  the  panjtid  into  its  two  divisions,  one  of  which  continues 
dow-nward  to  the  lower  border  of  the  gland  to  become  the  external 
jugular  while  the  other,  passing  downward  and  forward,  joins  the 
internal  jugular.  The  number,  size  and  deep  situation  of  the  vessels 
in  the  narrow  and  deep  parotid  region  accounts  for  the  gravity  of 
wounds  of  this  region  when  one  of  the  vessels  is  injured. 

From  the  circumference  of  the  surface  of  the  gland  many  of  the 
contained  nerves  and  arteries  take  their  exit ;  posteriorly  the  posterior 
auricular  artery,  superiorly  the  auriculotemporal  nerve  and  the  super- 
ficial temporal  artery,  anteriorly  the  transverse  facial  artery  and  the 
branches  of  the  facial  nerve  as  well  as  Stenson's  duct. 

Both  superficial  to  and  within  the  substance  of  the  gland  are  a  num- 
ber of  lymph  nodes  which  receive  lymph  from  the  temporal  and  frontal 
regions  of  the  scalp,  the  outer  part  of  the  eyelid,  the  orbit,  the  cheek, 
the  nasal  fossa,  the  nasopharynx,  the  external  auditory  meatus  and  the 
intracranial  parts.  They  empty  into  the  deep  and  superficial  cervical 
nodes.  These  lymph  nodes  when  enlarged  form  one  variety  of  parotid 
tumor.  The  sources  from  which  they  derive  their  lympii  supply 
should  be  examined  for  the  presence  of  lesions,  in  diagnosing  between 
lymphatic  enlargements  and  other  parotid  tumors.  Abscess  on  the 
surface  or  within  the  gland  may  be  due  to  an  inflammation  of  these 
nodes.     The  deep  nodes  are  found  especially  along  the  carotid  artery. 

Tumors  of  the  parotid  are  not  uncommon  and  mixed  tumors,  con- 
taining cartilaginous,  myxomatous  and  fibrous  portions,  occur  quite 
often  among  them.  In  addition  there  are  malignant  tumors  or  malig- 
nant degeneration  of  benign  tumors.  It  is  a  striking  fact  that  the 
testis,  in  which  metastases  after  mumi)s  are  quite  common,  is  also  one  of 
the  few  other  soft  parts  where  cartilage  occurs  in  tumors.  The  henign 
tumors  are  often  encapsulated  and  involve  only  a  portion  of  the  gland 
so  that  their  extirpation  may  be  readily  accomplished  and  the  facial 
nerve,  perhaps  somewhat  disjilaood,  may  be  sj,ared  in  whole  or  in  part. 
It  has  been  much  discussed  whether  the  entire  gland  can  be  or  should 


92  THE  HEAD  AND  NECK. 

be  removed  when  involved  in  a  new  growth,  especially  a  malignant 
one.  The  operation  is  difficult,  but  it  certainly  can  and  should  be 
done  if  the  tumor  is  confined  within  the  capsule  of  the  gland.  It  is 
to  be  expected  that  the  facial  nerve  must  be  sacrificed,  but  the  result 
of  this  is  often  not  so  distressing  as  might  be  expected.  I  have  found 
the  operation  entirely  feasible  in  a  recent  case  of  removal  of  the  entire 
parotid  involved  in  a  recurrent  endothelioma.  Tiie  external  carotid 
and  external  jugular  are  tied  in  the  earlier  stages  of  the  operation  for 
the  bleeding  is  very  free  from  the  arterial  branches,  including  the  tem- 
poral, internal  maxillary,  posterior  auricular,  and  transverse  facial 
arteries  and  the  branches  supplying  the  gland.  Incimons  over  the 
parotid  for  minor  conditions  should  be  transverse  so  as  to  avoid  the 
branches  of  the  facial  nerve. 

The  upper  and  lower  jaws  are  both  susceptible  to  phosphorus  necrosis 
among  those  who  work  with  phosphorus,  as  in  match  factories,  but  it 
is  almost  confined  to  those  with  carious  teeth.  I  have  also  seen  it  in 
an  old  colored  man  who  took  phosphorus  internally  for  a  long  time  to 
keep  up  his  sexual  vigor.  There  is  usually  an  osteoplastic  periostitis 
resulting  in  the  production  of  osteophytes,  which  themselves  are  liable 
to  necrose. 

The  upper  jaw  or  maxilla  is  .supported  or  buttressed  above  and 
internally  by  the  articulation  with  the  frontal  and  nasal  bones,  above 
and  externally  by  the  vertical  portion  of  the  malar,  behind  by  the 
pterygoid  process,  externally  by  the  zygomatic  arch,  internally  by  the 
articulation  with  the  opposite  maxilla  in  the  hard  palate.  Thus  sup- 
ported it  is  not  very  often  fractured  but  it  may  be  by  direct  or  indirect 
violence.  In  the  latter  manner  the  shock  is  usually  transmitted 
through  the  lower  jaw  as  in  a  fall  or  blow,  more  rarely  through  the 
head  while  the  chin  is  fixed,  sometimes  through  the  malar  bone  which, 
on  account  of  its  density,  is  seldom  fractured  but  may  be  driven  into 
the  upper  jaw.  Fracture  by  direct  violence  may  be  due  to  a  direct 
injurv  over  a  circumscribed  area  or  to  the  violent  extraction  of  a  tooth. 
The  maxilla  is  partly  protected  from  direct  violence  by  the  prominence 
of  the  nose  internally  and  the  mahir  bone  externally.  When  the  ivall 
of  the  antrum  is  fractured  it  may  be  much  depressed,  depending  upon 
the  direction  and  degree  of  the  force.  Whether  it  is  depressed  or  not 
subcutaneous  emphysema  may  occur  and  is  increased  on  blowing  the 
nose.  In  other  cases  pain  referred  to  the  dental  or  infraorbital  nerves 
may  lead  to  the  diagnosis  ;  thus  in  one  case  my  attention  was  first 
called  to  a  fracture  through  the  infraorbital  margin  and  canal  by  pain 
in  the  nerve. 

Althougii  the  maxilla  is  very  vascular,  yet  its  periosteum,  like  that 
of  the  skull,  is  not  likely  to  form  new  iione  so  that  there  is  no  repro- 
duction after  necrosis.  The  infraorbital  margin  is  the  favorite  seat  of 
tubercular  periostitis  and  osteomyelitis  of  the  maxilla. 

The  fact  that  the  maxilla  is  connected  witii  the  surrounding  bony 
parts  at  four  poi)its  is  important  to  remember  in  its  excision,  which  is 
undertaken  in  case  of  malignant  tumors,  etc.      (1)  The  connection  with 


EXCISION  OF  THE   UPPER  J  A  W.  93 

the  malar  bone  is  divided  by  a  wire  or  ciuun  saw  passed  through  the 
fore  part  of  the  sphenomaxillary  fissure  after  raising  up  the  perios- 
teum of  the  orbital  floor.  (2)  The  nami  proccs.s,  together  with  the 
lachrymal  bone  and  the  orbital  plate  of  the  ethmoid,  is  divided  by  the 
bone  forceps  whose  blades  are  introduced  into  the  nasal  fossa  and  the 
orbit  below  the  tendo  oculi.  In  some  cases  most  of  the  orl)ital  floor 
may  be  left,  the  section  passing  just  behind  or  sometimes  below  the 
orbital  margin.  (3)  The  hard  palate,  by  which  the  opposite  maxilla 
and  palate  bones  are  connected  together,  is  divided  by  a  saw  or  bone 
forceps  after  extracting  a  central  incisor  and  dividing  and  strijjping  up 
the  muco-periosteum  on  its  under  surface.  (4)  Its  connection  behind 
with  the  pterygoid  process  and  the  intervening  palate  bone,  as  well  as 
Avith  muscular  attachments  (external  pterygoid),  are  freed  by  twisting 
the  bone,  to  ((raid  unnecessary  injury  to  the  branches  of  the  internal 
maxillary  artery.  Before  this  last  step  in  the  removal  of  the  jaw  it  is 
well  to  cut  the  infraorbital  nerve  at  the  back  of  its  groove  in  the  floor 
of  the  orbit  and  to  divide  the  connection  of  the  fioft  palate  with  the 
back  of  the  hard  palate  on  the  aifected  side.  The  bony  connections 
are  divided  in  the  order  named. 

To  ra7j0.sc  the  maxilla /or  excision  the  soft  parts  are  divided  down  to 
the  bone  along  the  lower  margin  of  the  orbit  to  the  side  of  the  nose, 
thence  in  the  groove  between  the  nose  and  the  cheek  and  the  nose  and 
the  lip  to  the  ridge  on  the  side  of  the  filtrum  of  the  lij)  and  down  this 
ridge  through  the  lip.  In  this  inci.sio)i  the  following  ncrve.s  a)id  vcssek 
are  cut  in  the  following  order  from  above  downwards ;  the  palpebral 
branches  of  the  infraorbital  vessels  and  nerve,  angular  artery  and  vein, 
lateralis  nasi  vessels,  nasal  branches  of  the  infraorbital  nerve  and  the 
superior  coronary  vessels.  Several  small  branches  of  the  facial  nerve 
may  also  be  cut.  Notice  that  no  large  vessels  are  divided  in  the  soft 
parts  and  the  same  may  be  said  of  the  bone  section,  though  the  opera- 
tion may  appear  bloody  from  the  many  small  branches  divided.  The 
attachment  of  the  lateral  cartilages  of  the  nose  to  the  bone  are  divided, 
thus  opening  up  the  anterior  nasal  orifice.  The  flap  is  then  turned, 
back,  keeping  close  to  the  bone  if  the  soft  parts  are  not  involved  and 
in  any  case  taking  care  to  preserve  the  facial  artery  and  vein  and  to 
avoid  Stenson^s  duct.  The  latter  may  be  acconijilished  by  remembering 
its  course  and  dividing  the  mucous  membrane  close  to  the  gums  so  as 
to  avoid  the  orifice  of  the  duct,  4  mm.  above  this  point. 

The  division  of  the  mucous  niend>rane  may  be  left  toward  the  last  to 
avoid  the  flow  of  blood  into  the  mouth.  In  rare  cases,  but  not  as  a 
rule,  the  muco-periosteum  of  the  palate  may  be  spared  by  dividing  it 
close  to  the  alveolar  margin,  strijiping  it  up  and  subsequently  suturing 
it  to  the  mucosa  of  the  cheek,  thus  roofing  over  the  oral  cavity.  The 
s/cin  flap  is  well  nourished  by  the  facial  and  transverse  facial  vessels 
and  is  supplied  by  the  facial  nerve.  The  scar  is  almost  imperceptible 
in  time.  By  stripping  nj)  the  periosteum  of  the  orbital  floor  the  con- 
tents of  the  orbit  are  spared,  but  the  origin  of  the  inferior  oi)liquc  muscle 
is  detached.      In  dividing  the  nasal   process  of  the   maxilla  and  the 


94  THE  HEAD  AND   XECK. 

lachrymal  bone  the  lachrymal  sac  or  the  naml  duct  will  be  cut  across. 
If  the  nasal  process  is  removed  high  up  the  origin  of  the  tendo  oculi 
is  included.  In  the  last  step  of  twisting  oif  the  maxilla  the  descend- 
ing palatine  artery  and  great  palatine  nerve  are  severed.  In  some 
cases  where  the  tumor  involves  only  a  part  of  the  maxilla,  most  com- 
monly the  alveolar  process,  the  excision  may  be  partial,  sparing  in 
such  a  case  the  orbital  floor  and  margin. 

Again  temporary  resection  of  the  maxilla  is  practiced  to  gain  access 
to  the  nasopharynx  in  order  to  remove  polypi  situated  there ;  or  to 
expose  the  orbit,  sphenomaxillary  or  temporal  fossae  in  order  to  remove 
tumors  or  excise  nerves  situated  in  these  parts.  In  temporary  resection 
the  alveolar  arch  and  palcde  are  left  undisturbed ,  the  section  passing 
into  the  nose  above  them  ;  the  connection  with  the  malar  bone  is  sev- 
ered and,  after  another  horizontal  section  is  made  from  the  orbit  to  the 
nasal  fossa,  tlie  bone  flap  is  turned  inward  as  on  a  hinge,  breaking  the 
nasal  process,  and  is  replaced  at  the  end  of  the  0})eration. 

The  lower  jaw  or  mandible  is  more  often  fractured  than  any  other 
bone  of  the  face,  in  spite  of  its  free  mobility,  the  buffer-like  interartic- 
ular  cartilages  and  its  horseshoe  shape,  which  gives  it  increased  elas- 
ticity. It  may  be  broken  by  direct  or  indirect  violence.  In  the  latter 
case  the  pressure  increases  the  curve  until  it  gives  way,  usually  at  its 
weakest  point  near  the  symphysis.  It  is  more  often  fractured  by 
direct  violence  and  in  this  case  also  most  often  near  the  sympjhysis. 
The  line  of  fracture  may  be  nearly  vertical,  especially  when  at  or  near 
the  symphysis,  or  more  oblique,  in  most  cases  of  fracture  further 
back. 

The  displacement  depends  upon  the  position  and  direction  of  the 
fracture  and  the  direction  of  the  force.  In  general  the  elevator  mus- 
cles attached  to  the  ramus  draw  the  posterior  fragment  upward,  forward 
and  outward  while  at  the  same  time  the  depressor  muscles,  digastric, 
mylohyoid  and  geniohyoid  draw  the  anterior  fragment  backward, 
downward  and  inward.  In  case  of  a  fracture  of  the  ramus  itself  the 
muscles  attached  to  it  hold  the  fragments  together.  In  double  frac- 
tures, which  are  quite  common,  the  intermediate  fragment  may  be  dis- 
placed downward  and  backward.  The  displacement  in  fractures  of 
the  body  of  the  bone  is  usually  plainly  visible  in  the  difference  oi  level 
of  the  teeth. 

Although,  owing  to  the  firm  character  and  close  attachment  of  the 
gums  to  the  bone,  fractures  of  the  body  of  the  lower  jaw  are  almost 
always  compounded  in  the  mouth  and  are  thus  exposed  to  bacterial 
infection,  these  fractures  generally  do  well  if  kept  in  good  pjosition. 
This  we  may  accomplish  by  splinting  the  lower  against  the  upper  jaw 
by  the  pressure  of  bandages,  preferably  with  an  interdental  ^tpHid.  inter- 
vening. A  fracture  posterior  to  the  mental  foramen  may  injure  the 
inferior  dental  nerve  so  as  to  be  very  painful  and  sometimes  to  cause 
anaesthesia  of  the  lower  lip  and  chin,  supplied  by  its  mental  branch. 
The  nerve  escapes  injury  more  often  than  one  would  suppose  and  it 
has  been  in  rare  instances  compressed  later  on  by  the  callus. 


EXCISIOy   OF   THE  LOWER  ./.111'.  95 

Speech  is  interfered  with  on  account  of  the  attachment  of  the  muscles 
of  the  tongue  and  the  floor  of  the  mouth  to  the  jaw.  If  the  attach- 
ment of  the  genioglossus  is  displaced  backward  in  a  fracture  or  is 
divided  in  excision  of  the  jaw  some  trouble  may  be  experienced  from 
the  tongne  fdUing  backward  and  blocking  the  pharynx.  The  condi/le  is 
occasionally  broken  on  one  or  both  sides  by  direct  blows  or  blows  on 
the  chin,  and  I  have  seen  an  oblique  fracture  of  the  ramus  running 
from  behind  downward  and  forward  and  separating  the  region  of  the 
an(//e  from  the  rest  of  the  bone.  Fractures  of  the  alveolar  process  are 
common  in  connection  with  pulling  teeth. 

The  lower  like  the  upper  jaiv  may  be  the  seat  of  ma/ignant  fumoi's, 
especially  sarcoma,  w'hich  as  well  as  extensive  necrosis  may  call  for 
excision  of  half  of  the  jaw,  more  or  less.  Excision  of  the  entire  jaw  is 
rare.  Epulis,  usually  a  sarcoma  of  the  alveolar  process  of  the  lower 
or  upper  jaw,  may  be  excised  from  within  the  mouth,  well  within 
sound  tissue.  In  excising  half  of  tJie  mandible  an  incision  is  made 
down  to  bone  along  its  lower  border,  commencing  a  little  beyond  the 
median  line.  It  is  not  necessary  to  extend  it  up  the  back  of  the  ramus 
and  if  this  is  done  it  should  not  extend  more  than  2  cm.  for  fear  of 
wounding  the  facial  nerve  or  even  Stenson's  duct.  Except  in  large 
tumors  it  is  not  necessary  to  incise  vertically  through  the  lower  lip. 

The  horizontal  incision  divides  the  facial  vessels  at  the  antero-infe- 
rior  angle  of  the  masseter,  also  some  branches  of  the  facial  and  super- 
ficial cervical  nerves.  If  the  lip  is  incised  in  the  median  line  the 
anastomoses  between  the  inferior  coronary,  inferior  labial  and  sub- 
mental vessels  of  the  two  sides  are  divided.  The  bone  is  then  freed 
of  its  muscular  attachments,  keeping  close  to  the  bone.  Except  when 
there  is  a  malignant  growth,  which  has  reached  to  or  developed  from  the 
surface,  the  jaw  may  often  be  excised  snbperiosteally,  largely  by  blunt 
dissection.  In  this  connection  Tillaux  has  called  attention  to  the  im- 
portance and  the  feasibility  of  preserving  the  periosteum  covering  the 
angle  and  adjoining  parts  which  connect  together  the  attachments  of 
the  masseter  and  internal  pterygoid  muscles.  The  entire  jaiv  has  been 
reproduced  after  subperiosteal  removal. 

It  is  sometimes  difficult  even  with  much  depression  to  free  the  at- 
tachment of  the  temporal  muscle  which,  it  should  be  remembered,  is 
attached  to  the  margins  and  the  inner  surface  of  the  coronoid  process. 
The  tip  of  the  latter  is  sometimes  cut  off  with  the  bone  forceps  in  place 
of  detaching  the  muscle.  As  to  the  condi/lc  it  is  best  at  the  last  to 
twist  it  ofl'  instead  of  cutting  the  capsule  and  the  insertion  of  the 
external  pterygoid,  on  account  of  the  danger  of  wounding  the  internal 
maxillary  artery  as  it  winds  around  the  neck  of  the  condyle.  The 
inferior  dental  vessels  and  ncrrc  and  their  mylohyoid  branches  are  of 
course  divided  close  to  the  inferior  dental  foramen.  In  lan/e  tumors 
care  should  also  be  taken  to  avoid  the  salivary  glands,  the  external 
carotid  artery,  the  temporomaxillary  vein  and  the  lingual  and  auriculo- 
temporal nerves.  Cysts  and  /('//jo/-.s'of  the  jaws  may  also  develop  from 
the  tooth  germs.     In  a  central  sarcoma  or  other  tumor  jxi in  from  pres- 


96  THE  HEAD  AND  NECK. 

sure  on  the  dental  nerves  may  be  one  of  the  earliest  symptoms  noticed. 
Congenifalli/,  and  depending  upon  defective  development  of  the  first 
branchial  arch,  the  jaw  has  in  rare  cases  been  cleft  at  the  symphysis, 
incompletely  formed  or  entirely  absent. 

Temporomandibular  Joint. — The  condyle  can  be  seen  and  felt  as 
a  slight  projection  immediately  in  front  of  the  tragus  of  the  ear,  from 
which  point  it  can  be  seen  and  felt  to  move  forward  and  downward 
onto  the  articular  eminence  when  the  mouth  is  widely  opened.  In 
dislocation  the  condyle  passes  forward  and  upward  from  the  eminence 
into  the  zygomatic  fossa  The  depression  which  is  seen  and  felt  in 
place  of  the  normal  projection  in  front  of  the  tragus  is  a  valuable  sign 
of  dislocation,  especially  Avhen  it  is  unilateral.  The  honi/  external 
auditory  meatus  is  immediately  behind  the  joint  and  in  falls  or  blows 
on  the  chin  the  condyle  may  be  driven  upward  through  the  glenoid 
fossa  fracturing  the  base  of  the  skull  or  backward  fracturing  the  ante- 
rior wall  of  the  meatus.  In  the  latter  way  only  is  a  posterior  dis- 
location possible.  The  direction  of  the  fibers  of  the  only  strong  liga- 
ment of  the  joint,  the  externcd  lateral,  is  downward  and  backward  so 
that  it  resists  the  backward  movement  of  the  condyle  and  thus  pro- 
tects the  wall  of  the  meatus  from  more  frequent  injury. 

Dislocation  of  this  joint  is  permitted  in  the  foricard  directly  only, 
with  the  above  exception.  It  occurs  only  when  the  mouth  is  ividely 
open  and  the  condyle  is  on  the  eminentia  articularis  from  which  it  is 
pulled  forward  by  the  external  pterygoid  in  violent  yairning,  laughing 
or  vomiting,  in  dentists' operations,  and  in  the  violent  introduction  into 
the  mouth  of  large  objects.  When  the  condyle  is  pulled  in  front  of 
the  articular  eminence  it  c/lides  upward  along  the  inclined  surface  in 
front  of  the  eminence  and  is  pulled  up  by  the  elevator  muscles.  The 
jaw  however  can  not  be  closed  but  is  held  icidely  opened  and  the  fixity 
of  this  position  and  the  difficulty  of  reduction  is  explained  in  different 
ways.  (1)  The  direction  of  the  fibers  of  the  external  latercd  ligament 
is  reversed  in  the  new  position  of  the  condyle  and  the  attempt  to  close 
the  jaw  now  puts  this  ligament  on  the  stretch.  The  same  is  true  of  an 
attempt  to  push  the  jaw  backward,  for  it  has  to  pass  downward  to  pass 
beneath  the  articular  eminence.  A  doimward  as  well  as  backward 
pressure  is  therefore  necessary  in  the  reduction  of  the  dislocation  and 
this  can  be  eflfected  with  the  least  tension  of  the  external  ligament  if 
the  jaw  is  at  first  kept  widely  open  or  even  opened  more  widely.  It 
is  not  true,  however,  as  is  sometimes  stated,  that  the  external  lateral 
ligament  is  relaxed  when  the  mouth  is  wide  open  but  rather  the 
reverse,  for  the  ligament  is  tightened  by  depression  of  the  jaw  and  by 
the  downward  gliding  onto  the  articular  eminence  more  than  it  is 
relaxed  by  the  fi)rward  movement  of  the  condyle. 

(2)  In  the  comi)ined  hinge  and  sliding  movement  of  the  jaw  the  con- 
dyle moves  forward,  the  angle  backward  and  the  axis  of  motion,  or  the 
part  which  moves  least,  is  about  the  center  of  the  ramus,  or  at  the  infe- 
rior dental  foramen.  Hence  the  vessels  and  nerves  which  enter  this 
foramen  are  not  subject  to  traction   and  displacement  as  they  other- 


DISLOCATIOX   OF  TIIK  LOWER  JAW 


97 


wise  would  he.  The  line  of  action  of  the  masseter  and  internal 
pterygoid  muscles  normally  passes  upward  and  forward  in  front  of 
this  axis.  AVhen  however  the  jaw  is  dislocated  forward  the  line  of 
action  of  these  muscles  is  displaced  somewhat  backward  with  the 
angle,  while  the  axis  of  motion  is  displaced  in  front  of  it.  (Fig.  24.) 
Hence  while  normally  the  action  of  these  muscles  is  to  elevate  the  front 
of  the  jaw  and  depress  the  angle,  in  a  dislocated  jaw  their  action  is  to 
elevate  the  angle  and  depress  the  front  of  the  jaw,  /.  e.,  to  open  it.  That 
the  muscl€>t  are  .yja.siiioflical/ij contracted,  from  their  lieing  injured  or  put 
on  the  stretch  or  from  pressure  or  traction  on  their  nerves  can  be  readily 
felt.  According  to  Tillaux  a  dislocation  is  produced  when  in  a  vio- 
lent opening  of  the  mouth  the  axis  of  motion  is  carried  in  front  of  the 
line  of  muscular  action.  In  a  dislocation  the  condyle  may  be  said  to 
be  held  bv  a  balance  of  forces  between  the  external  lateral   lioament 


Fig.  24. 


DIRECTION     OF    EXT. 
LATERAL    LIGAMENT 


INTERAHTIC. 

FIBRO- 

CARTILAGE 


LINE    OF    ACTION    OF 
ELEVATOR     MUSCLES 

AXIS    OF    MOVEMENT 
OF    DISLOCATED    JAW 

AXIS    OF    MOVEMENT g 

OF   JAW 


Figure  to  show  the  relation  of  the  line  of  actiou  of  tlie  niasseter  ami  internal  ptervcoid  muscles  to 
the  axis  of  movement  of  the  lower  jaw  in  its  normal  position  and  in  dislocation.  The  Jotted  line  rej)- 
resents  the  position  of  tne  dislocated  jaw.    (Tillaux.) 


pulling  upward  and  backward,  and  the  muscles  pulling  upward  and 
forward.  (3)  It  is  possible  in  rare  cases,  as  in  the  specimen  in  the 
Musee  Dupuytren,  that  the  apex  of  an  unusually  lone/  cnronoid  process 
may  be  caught  against  the  malar  i)one  and  resist  reduction. 

In  dislocation  the  Jihrocdrti/df/c  may  pass  forward  with  the  condyle 
or  it  may  remain  behind  in  the  glenoid  fossa  and  in  the  latter  case  the 
anterior  part  of  the  capsule  may  be  torn.  The  posterior  part  of  the 
capmie  is  much  stretched  and  often  torn.  The  dislocation  may  occur 
on  one  or  both  sides. 


98  THE  HEAD  AND  NECK. 

The  lower  jaw  is  sometimes  held  firnihi  cloned.  This  may  be  due  to 
a  tonic  spasm  of  the  muscles  of  mastication,  a  condition  known  as 
trismus  or  lockjaw.  This  may  be  an  early  symptom  of  tetanus  or  a 
rejie.v  symptom  due  to  the  irritation  of  one  of  the  sensory  branches  of 
the  fifth  nerve,  especially  those  of  the  lower  teeth.  The  nerve  to  the 
muscles  of  mcustication  is  the  only  motor  branch  derived  from  the  fifth 
nerve. 

Again  the  firm  closure  of  the  jaw  may  be  due  to  a  cicatricial  con- 
traction following  a  cancrum  oris  or  other  large  loss  of  substance  of  the 
cheek  or  to  an  anchylosis  of  the  temporomandibular  joint.  In  the 
latter  case  an  excision  of  the  neck  of  the  condyle  is  done  to  secure  a 
false  joint. 

The  two  lips  unite  laterally  at  the  cominissures  to  enclose  a  trans- 
verse aperture  (the  buccal  orifice)  popularly  called  the  mouth,  but  the 
latter  term  should  apply  to  the  cavity  to  which  the  opening  leads. 
The  lips  consist  of  the  following  layers:  (1)  Skin  closely  adherent  to 
(2)  a  muscular  layer  (orbicularis  oris),  (3)  labial  mucous  glands  among 
which  are  the  coronary  vessels  and  (4)  mucous  membrane. 

The  thick  skin  joins  the  mucous  membrane  along  the  free  border  by 
an  intervening  ^^  vermilion  border,''^  or  dry  mucous  membrane,  which  is 
remarkable  for  its  sensitiveness  and  the  frequent  occurrence  of  epithe- 
lioma, especially  on  the  lower  lip.  This  border  on  the  upper  lip  pre- 
sents a  median  tubercle,  the  remains  of  the  free  extremity  of  the  fronto- 
nasal process.  From  this  tubercle  up  to  the  columna  nasi  is  a  shallow 
groove,  the  filtrum,  bounded  by  two  low  ridges  along  which  vertical* 
incisions  are  carried  if  it  is  desired  to  show  as  little  scar  as  possible. 

The  muscular  fibers  run  mostly  parallel  with  the  buccal  orifice,  hence 
incisions  to  open  abscesses,  etc.,  should  be  horizontal,  for  a  vertical  in- 
cision is  followed  by  considerable  retraction  of  the  edges.  Into  the 
orbicularis  oris  are  inserted  most  of  the  muscles  of  expression. 

The  glandular  layer  is  formed  of  racemose  glands  resembling  the 
salivary  glands.  It  may  hypertrophy  as  a  whole,  thickening  the  lip, 
or  the  individual  glands  may  form  retention  cysts.  On  a  vertical  sec- 
tion of  the  lips  this  layer  protrudes  while  the  muscular  layer  retracts. 
The  coronary  arteries  are  embedded  in  this  layer  close  beneath  the 
mucosa  and  nearer  the  free  than  the  attached  margin  of  the  lips,  about 
one  half  inch  from  the  former.  Bleeding  from  them  may  be  easily 
'prevented  or  stopped  by  pressure  of  the  fingers  or  a  temporary  ligature. 
In  .suturing  vertical  incisions  of  the  lip,  as  in  harelip  operations,  one 
suture  should  be  passed  behind  both  ends  of  the  artery,  between  it  and 
the  mucosa,  to  check  the  hemorrhage.  The  coronary  arteries  can  re- 
tract freely  into  the  loose  tissue  in  which  they  lie  so  that  bleeding  is 
often  spontaneously  arrested.  As  the  superior  coronary  artery  sends 
a  branch  to  the  septum  nasi,  compre.mon  of  the  artery  may  check  nose 
bleed.  The  vascularity  of  the  lips,  from  the  coronary  and  other  arteries, 
accounts  for  the  frequent  presence  of  nsevi  and  other  vascular  tumors 
as  well  as  for  the  ready  healing  of  the  many  plastic  operations  per- 
formed to  relieve  deformities  and  fill  the  gaps  left  by  the  removal  of 


HARELIP.  99 

new-growths  about  the  mouth.  The  success  of  these  operations  is  also 
favored  by  the  laxity  and  mobility  of  the  tissues  about  the  mouth. 
The  vessels  of  the  two  sides  of  the  lips  anddomose  freely,  hence  both 
ends  of  a  divided  vessel  should  be  tied.  The  connection  of  the  veins 
through  the  facial  and  ophthalmic,  with  the  cavernous  sinuses  should 
be  remembered  in  inflammatory  conditions  of  the  lips. 

The  lymphatics  pass  to  the  submaxillary  and  suprahyoid  nodes  so 
that  these  nodes  may  be  involved  and  re<iuire  removal  in  epithelioma 
of  the  lip.  The  nerves  of  the  upper  lip  (infraorbital)  come  from  the 
second  division,  those  of  the  lower  lip  (inferior  dental)  from  the  third 
division  of  the  fifth  nerve.  There  are  numerous  end  bulbs  resembling 
tactile  corpuscles  in  the  sensitive  vermilion  border.  Over  the  labial 
nerves  a  crop  of  herpes  [herpes  lahiali.s)  often  appears. 

The  mucous  membrane,  reflected  onto  the  gums  above  and  below  at 
the  attached  margin  of  the  lips,  presents  on  each  lip  a  small  median 
fold  or  frenulum  of  Avhich  the  upper  is  the  larger.  In  extensive 
plastic  operations,  as  after  the  removal  of  a  large  epithelium  of  the  lip, 
it  is  essential  for  a  good  and  permanent  result  that  the  flap  should  be 
lined  by  mucous  membrane,  otherwise  it  becomes  adherent  to  the  jaw 
and  immovable  and  does  not  oppose  the  dribbling  of  saliva.  In  case 
the  new-growth  is  smaller  a  V-shaped  incision  with  suture  of  the 
edges  suffices. 

Development. — In  the  foetus,  near  the  end  of  the  second  week  the 
buccal  and  nasal  cavities  are  one,  bounded  above  by  the  frontonasal 
process,  laterally  by  the  superior  maxillary  processes  and  below  by  the 
first  visceral  arch.  These  two  cavities  are  separated  by  the  median 
fusion  of  the  frontonasal  and  superior  maxillary  processes  to  form  the 
upper  lip  and  palate,  as  well  as  the  upper  part  of  the  face. 

The  lower  lip  is  formed  by  the  median  fusion  of  the  coverings  of  the 
lateral  halves  of  the  first  visceral  or  mandibular  arch.  Failure  of  this 
fusion,  resulting  in  a  median  cleft  of  the  lower  lip,  is  very  rare  and 
only  a  few  instances  of  it  are  on  record.  The  upper  lip  is  formed  by 
the  fusion  of  the  coverings  of  the  two  laterally  placed  superior  maxil- 
lary processes  and  the  median  frontonasal  process.  Failure  of  this 
fusion  on  one  or  both  sides  of  the  frontonasal  process  causes  single  or 
double  harelip.  Hence  this  is  lateral  and  not  median  ;  a  median  cleft, 
like  that  of  the  hare,  being  very  rare  and  otherwise  formed.  Harelip 
is  more  often  sinr/le  and  on  the  left  side  and  is  commoner  in  males.  It 
may  involve  part  of  the  lij)  only  or  extend  up  into  the  nostril.  In 
the  latter  case  it  is  often  combined  with  a  cleft  of  the  (dreohtr  arch  or 
of  the  palate  as  well. 

In  double  harelip  the  central  insulated  part  of  the  lip  often  appears 
as  a  nodule  attached  to  or  suspended  from  the  nose,  for  it  protudes  on 
the  intermaxillary  bone  which  ])rojects  forward  at  the  end  of  the  vomer. 
This  condition  is  due  to  the  fact  that  the  intermaxillary  bone,  the  sep- 
tum of  the  nose  and  the  central  part  of  the  lip  are  formed  bv  the 
frontonasal  jirocess.  In  single  harelip,  or  on  one  side  of  a  double 
harelip,  there  may  be  a  projcetion  of  the  alreolar  arch  on   the  median 


100  THE  HEAD  AND  NECK. 

side  of  the  cleft,  making  its  closure  more  difficult,  so  that  the  projection 
should  first  be  reduced. 

According  to  Albrecht,  the  cleft  is  between  the  frontonasal  and  the 
lateral  frontal  processes,  but  its  location  is  not  always  the  same. 
Harelip  is  opposite  the  interval  between  the  central  and  lateral  inci- 
sors or  between  the  latter  and  the  canine  tooth.  The  superior  max- 
illary process,  according  to  Albrecht,  is  only  concerned  in  the  oblique 
facial  cleft  which,  according  to  him,  is  due  to  the  non-union  of  the 
lateral  frontal  and  superior  maxillary  processes. 

The  cure  of  harelip  by  plastic  operation  is  very  satisfactory.  The 
two  halves  of  the  lip  must  first  be  freed  from  the  maxilla,  to  which 
they  are  unusually  adherent,  the  edges  freshened  in  one  of  several 
ways  and  then  sutured.  Transverse  facial  clefts,  due  to  failure  of 
fusion  of  the  mandibular  arches  and  the  superior  maxillary  process, 
commence  at  the  corners  of  the  mouth  and  cause  an  enlargement  of 
the  latter  (inacrostoma).  The  opposite  condition,  or  atresia  of  the  buc- 
cal orifice,  occurs  when  the  fusion  exceeds  the  normal  limits  or  it  fol- 
lows contraction  due  to  pathological  processes,  such  as  burns,  or  faulty 
plastic  operations.      It  may  also  be  relieved  by  operation. 

When  the  jaws  are  closed  there  exists  between  them  and  the  cheeks 
and  lips  a  space  known  as  the  vestibule  of  the  mouth.  The  circum- 
ference of  this  space  is  bounded  by  the  reflection  of  the  mucous  mem- 
brane from  the  gums  to  the  cheeks  and  lips.  Through  this  reflection 
we  may  incise  to  expose  the  infraorbital  and  mental  nerves  and  to  open 
the  antrum,  as  described  above.  It  is  near  this  line  of  reflection  that 
we  find  the  ahsce.sses  which  are  developed  from  a  fistulous  tract  leading 
from  a  diseased  root  of  a  tooth.  Such  an  abscess  may  be  seen,  if 
within  the  vestibule,  or  felt  if  just  beyond.  At  the  back  of  the  vesti- 
bule, behind  the  last  molar,  is  a  space  usually  large  enough  for  the 
passage  of  a  feeding  tube  in  case  of  trismus  ;  and  in  addition  liquids 
can  trickle  through  the  interstices  between  the  teeth.  The  anterior 
border  of  the  coronoid  jirocess  can  be  felt  plainly  at  the  back  of  the 
vestibule.  In  dislocation  it  is  much  more  appreciable  and  its  promi- 
nence may  be  an  aid  to  diagnosis.  In  addition,  as  this  border  passes 
down  onto  the  body  of  the  jaw,  external  to  the  alveolar  process,  it 
forms  a  kind  of  shelf  outside  of  the  last  molars  on  which  we  may  make 
pressure  with  the  thumbs  in  reducing  a  dislocation  of  the  jaw  and 
thus  avoid  the  danger  of  being  bitten  when  the  jaws  close  with  a  snap 
on  reduction.  The  d\ict  of  Stenson  opens  into  the  vestibule  (see  p. 
87). 

The  gums,  formed  by  the  closely  united  viucous  membrane  and 
periosteum  covering  the  alveolar  processes,  are  dense,  firm  and  vascu- 
lar, though  paler  in  color  than  the  adjacent  mucosa.  As  the  perios- 
teum of  the  gum  is  continuous  with  that  lining  the  sockets  of  the  teeth 
inflammation  originating  in  the  socket  from  a  carious  tooth,  especially 
a  single  fanged  tooth,  may  extend  up  and  out  of  the  socket  beneath 
the  periosteum  and  form  a  subperiosteal  alveolar  cdjscess  or ''gum- 
boil."    The  pain  is  considerable,  as  the  pus  is  bound  down  by  the 


Till-:  Thirni.  10 1 

dense  ^ums.  A  similar  iiiHanuuation  may  burrow  tliroiigh  the  l)ony 
wall  of  the  socket  and  appear  beneath  the  gums  a  little  further  from 
the  alveolar  margin  (see  above).  In  either  case  the  al)seess  may- 
open  or  be  opened  here  and  go  no  further,  or  it  may  extend  widely 
beneath  the  periosteum  and  cause  a  necrosis  ofthejaic.  If  the  end  of 
the  root  socket  of  a  tooth  is  beyond  the  limit  of  the  gums,  <tr  if  the  pus 
can  gravitate  beyond  it,  the  abscess  is  likely  to  break  throngh  the  cheek 
instead  of  through  the  gums.  Ulcerated  teeth  are  the  coimnon  cause  of 
necrosis  oi'  the  jaws  and  should  be  snspected  in  case  of  swelling,  abscess 
or  fistula  of  the  face  and  submaxillary  region.  A  similar  infammation 
in  the  sockets  of  the  upper  molars  may  spread  to  the  antrum  and  be 
the  canse  of  an  empneina  there. 

The  gums  covering  the  outer  and  inner  surfaces  of  the  alveolar  pro- 
cess are  continuous  in  the  interstices  between  the  teeth  and  are 
normally  closely  adherent  to  the  neck  of  the  teeth,  thereby  helping  to 
hold  them  in  so  that  when  the  gums  are  detached  the  teeth  are  more 
liable  to  become  loose.  From  the  gums  are  developed  a  class  of 
tumors  called  epulis  which  may  be  a  simple  fibrous  hypertrophy  of  the 
gums  or  a  sarcoma  developed  from  the  periosteum.  The  latter  form 
requires  the  removal  of  the  adjacent  portion  of  the  alveolar  process  to 
avoid  recurrence. 

In  old  age  as  in  infancy  the  gums  cover  the  upper  border  of  the 
jaw ;  in  the  former  case  they  are  very  thick  and  hard,  so  as  to  allow  a 
certain  amount  of  mastication,  in  the  latter  case  they  become  much  in- 
flamed and  cause  much  irritation  during  the  eruption  of  the  teeth.  In 
mercurial  poisoning  and  in  scurvy  the  gums  are  characteristically  con- 
gested and  s[)ongy,  so  that  they  bleed  readily  and  may  become  ulcer- 
ated. In  chronic  lead-poisoning  a  blue  line  of  sulphide  of  lead  may 
appear  along  the  dental  margins  of  the  gums,  due,  it  is  said,  to  the 
action  on  the  lead  of  hydrogen  sulphide  formed  by  the  decomposition 
of  food  debris  about  the  teeth,  if  the  latter  are  not  kept  clean. 

The  Teeth. — It  is  impracticable  to  try  to  remember  the  time  of 
eruption  of  each  of  the  ticentj/  temporari/  and  thirti/-two  permanent  teeth. 
The  order  of  appearance  is  much  more  regular  than  the  exact  time, 
which  is  liable  to  nuich  variation.  The  temporary  teeth  appear  in  the 
foUounwj  order,  lower  central  incisors,  upper  incisors,  lower  lateral  in- 
cisors and  the  four  anterior  molars,  the  four  canines  and  finally  the 
four  posterior  molars.  The  Jirxf  dentition  usually  Arr/Z/fN  in  the  seventh 
month  and  is  eomjtleted  at  the  age  of  2  or  2^  years.  The  lower  teeth 
apj)ear  before  the  uj)per.  In  rare  instances  a  child  is  born  with  teeth. 
Si/phi/itic  children  are  rather  prone  to  early  dentition  and  early  decay 
of  the  teeth.  Dentition  is  often  delayed  in  richrts  and  still  more  so  in 
cretinism  and  it  may  be  said  to  goon  in  a  manner  corresponding  to  the 
ossification  of  the  cranial  bones. 

In  the  permanent  set  a  similar  order  is  followed  excoj)t  that  the  first 
molars  {6-i/ear  molars)  are  the  first  to  appear,  usually  in  the  seventh 
year.  The  second  molars  {1  J-jiear  molars)  appear  i'rom  the  twelfth  to 
the  fifteenth  year,  the  third   molars,  or  wisdom  teeth,  from  the  seven- 


102  THE  HEAD  AXD  NECK. 

teenth  to  the  twenty-fifth  year,  or  they  may  never  appear,  in  which 
case  they  may  lead  to  the  formation  of  cysts  of  the  jaw.  It  is  to  be 
noticed  in  both  sets  that  the  canine  teeth  appear  after  those  on  either 
side  of  them  so  that  the  anterior  bicuspids  may  need  to  be  pulled  to 
make  room  for  the  canines. 

Certain  tumors  (odontonuita^  of  the  jaws  are  developed  from  the 
teeth  germs  or  growing  teeth.  They  form  tumors  within  the  sub- 
stance of  the  jaws  of  a  fibrous,  epithelial  or  bony  structure  according 
to  the  period  of  their  development  or  the  part  of  the  tooth  germ  from 
which  they  spring.  Cysts  of  the  jaws  have  a  similar  origin  from  the 
dental  sacs  and  retained  teeth,  as  well  as  sometimes  from  the  periosteum. 

The  enamel  of  the  teeth  is  developed  from  the  epithelium  of  the 
margin  of  the  gums  which,  becoming  thickened,  dips  into  the  sub- 
stance of  the  gums  as  the  "dental  shelf '^  and  forms  as  many  epithelial 
caps  or  enamel  organs  as  there  are  to  be  teeth  in  each  set.  Those  of 
the  pernmnent  set  lie  behind  those  of  the  temporary  set.  From  the 
dental  shelf  or  enamel  organs  are  formed  the  epithelial  odontomes.  The 
rest  of  the  tooth  grows  up  as  a  small  papilla  beneath  the  enamel  organ 
and  finally  becomes  capped  by  it. 

The  incisor  teeth  of  the  permanent  set  present  certain  pjeculiarities  in 
many  children  haying  hereditary  syphilis.  The  characteristic  or  "test 
teeth"  of  Hutchinson  are  the  upper  central  incisors  which  present  a 
single  crescentic  notch  in  the  center  of  the  free  edge.  These  syphilitic 
teeth  also  are  often  short,  thick  and  tapering. 

The  Floor  of  the  Mouth. — The  mylohyoid  muscle  forms  the  dia- 
phragm or  muscular  floor  of  the  mouth,  separating  the  buccal  cavity 
from  the  neck.  All  tumors  or  abscesses  developed  above  this  muscle 
project  or  point  into  the  buccal  cavity  and  may  be  operated  upon  by 
that  route ;  while  those  developing  below  the  muscle  present  in  the 
neck  and  may  best  be  reached  by  operation  there. 

The  tongue  occupies  the  greater  part  of  the  floor  of  the  mouth. 
Between  the  interlacing  >/(?/.sWe/7&f/-.s,  of  which  the  tongue  is  composed, 
is  a  comparatively  small  amount  of  connective  tissue.  It  is  note- 
worthy that  cellulitis  or  inflammation  of  this  tissue  [c/lo.ssitis)  is  uncom- 
mon ;  but  when  it  does  occur  the  tongue  may  swell  greatly  so  as  to 
threaten  asphyxia  by  pressing  down  the  epiglottis.  Owing  to  the  firm 
texture  of  the  tongue  and  its  thick  mucosa  abscess  in  its  substance  feels 
like  a  solid  tumor.  Foreign  bodices  may  easily  become  embedded  in 
the  tongue. 

The  tongue  is  not  attached  or  anchored  by  ligaments  but  by  its  extrinsic 
muscles,  to  the  mandible  by  the  genioglossi,  to  the  styloid  ])rocess  by 
the  styloglossi  and  to  the  hyoid  bone.  Hence,  in  anaesthesia,  when 
the  muscles  become  relaxed,  the  tongue  is  liable  to  drop  back  by  its  own 
weight  and  press  down  the  epiglottis  so  as  to  close  the  opening  into 
the  larynx.  This  tendency  may  be  diminisjied  by  placing  the  patient's 
head  on  the  side,  so  that  gravity  does  not  tend  to  force  the  tongue 
backward;  or  it  maybe  counteracted  by  pulling  the  tongue  forward 
either  directly,  by  the  tongue  forceps,  or  indirectly,  by  protruding  the 


THE  ToyauK. 


103 


jaw,  by  pressing  forward  heJtind  fhe  rami,  and  thereby  pulling  the  tongue 
through  the  genioglossi. 

The  tongue  normally  overhangs  the  entrance  of  the  larynx,  thereby 
hiding  it,  hence  if  the  tongue  is  drawn  too  far  forward  it  exposes  the 
larynx  and  favors  the  passage  of  food  or  other  fluids  into  it.  Similarly 
when,  in  operations  on  the  tongue  or  in  excision  of  the  fore  part  of  the 
lower  jaw,  the  genioglossi  muscles  are  divided  the  tongue  is  liable  to 
drop  back  if  the  patient  lies  upon  his  back.  Hence  precautions  are 
taken  to  have  the  patient  lie  upon  the  side,  to  fasten  the  tongue  forward 
by  suturing  its  base  to  the  mental  region  and  to  thread  the  tongue  with 
a  silk  suture,  whereby  it  may  i)c  pulled  forward  as  occasion  requires, 
until  adhesions  form  whicii  I'asten  it  in  position. 

Fsa.  25. 


Under  surface  of  tongue  and  the  sublingual  space,  showing  openings  of  salivary  ducts.  The  mucosa 
of  the  left  side  is  partly  removed,  aud  shows  the  rauine  artery,  the  lingual  nerve,  and  the  gland  of 
Blaudiu.     (OEKKisH,  after  TKsifi.) 

The  tongue  is  also  connected  by  mucosa  with  the  alveolar  arch 
and  by  folds  of  mucous  membrane  with  the  ei)iglottis,  the  soft  palate 
(enclosing  the  palatoglossus  muscle)  and  the  back  of  the  symphysis 
of  the  jaw.  The  latter  is  a  median  fold  known  as  the  fraenum  linguae 
which  normallv  ends  some  distance  short  of  the  tii)  of  the  tdnjruc.  In 
rare  instances  this  frsenum  extends  to  the  tij>  or  is  abnormally  short  so 
as  to  restrict  the  movements  of  the  tongue.  This  condition  of  "tongue- 
tie  "  may  prevent  the  infant  from  sucking  well  or,  later  in  life,  interfere 
with  articulation  and  necessitate  (//r/.s/o/j  of  the  fnenum.  This  may 
•be  done  after  lifting  up  the  tongue  by  tiie  fingers  or  the  back  end  of  a 


104  THE  HEAD   AND  XECK. 

grooved  director,  which  is  made  for  the  purpose.  In  such  cases  the 
free  edge  of  the  frfeiiuin  shoidd  be  divided  close  to  the  jaw  so  as  to 
avoid  the  ranine  veins  on  the  under  surface  of  the  tongue,  and  the 
freenum  may  be  torn  loose  as  much  as  required.  If  tliere  is  any  bleed- 
ing in  such  cases  it  is  encouraged  and  not  checked  by  the  infant's 
nursing. 

The  ranine  veins  just  mentioned  are  plainly  seen  beneath  the  mucosa 
of  the  under  surface  of  the  tongue,  less  than  half  an  inch  from  and  on 
eitlier  side  of  the  fraenum.  The  ranine  arteries  lie  a  little  more  later- 
ally and  more  deeply  phiced,  beneath  fringes  of  mucous  membrane 
which  converge  toward  the  tip. 

Surface  of  the  Tongue. — It  is  the  bright  red  color  of  the  fungiform 
papillae,  scattered  along  the  sides  and  tips  of  the  tongue,  contrasted 
with  the  coating  of  the  rest  of  the  tongue,  which  produces  the  so-called 
"  .■<tir(u-herrt/  tongue'^  of  scarlet  fever.  The  coating  of  the  tongue  is 
composed  of  a  mixture  of  desquamated  epithelium,  food  debris  and 
bacteria.  Behind  the  circumvallate  papillae  there  is  much  lymphoid 
tissue  in  the  mucous  membrane.  This  is  collected  into  rounded  masses 
which  are  sometimes  hypertrophied  to  form  an  irregular  nodular  mass 
known  as  the  lingual  tonsil,  which  may  require  removal  on  account  of 
its  impairing  the  movements  of  the  glottis.  The  foramen  cweum  at  the 
apex  of  the  circumvalUite  papillae  represents  the  upper  end  of  the  lin- 
gual or  thyroglossal  duct,  in  connection  with  the  lower  end  of  which 
the  thyroid  gland  is  devehiped.  From  or  contiguous  to  this  duct 
there  occasionally  develops  a  tumor  of  the  base  of  the  tongue  resem- 
bling the  thyroid  gland  in  structure.  Mucous  cysts  are  sometimes  de- 
veloped from  tlie  mucous  gUmds  which  abound  over  the  posterior  third 
of  the  tongue. 

The  surface  epithelium,  owing  to  chronic  irritation  or  inflammation, 
may  become  thickened  in  the  form  of  dense  opaque  plaques.  This 
condition,  variously  known  as  psoriasis  or  ichthyosis  lingwr,  leucoma 
and  smoker's  patch,  is  important  as  it  may  develop  into  epithelioma, 
which  is  common  in  the  tongue,  especially  on  the  side  of  the  anterior 
half  Tubercular  or  syphilitic  ulcers,  which  also  occur  on  the  tongue, 
may  sometimes  be  mistaken  for  it. 

The  treatment  of  epithelioma  is  excision  of  the  tongue  by  one  of  the 
various  methods  employed,  through  tlie  month  or  from  beneath  the 
jaw  and  with  or  without  previous  ligature  of  the  lingual  arteries  in  the 
neck  (see  p.  125).  In  operating  through  the  mouth  more  room  is 
obtained  by  stretching  the  mouth,  splitting  the  cheek  or  dividing  the 
lip  and  jaw. 

Hemorrhage  is  the  chief  obstacle  in  operating  through  the  mouth. 
It  is  not  the  amount  but  the  locality  of  the  bleeding  and  the  danger 
of  its  running  back  into  the  larynx  and  trachea  that  concerns  us. 
Hence  the  value  of  preliminary  Hg<dure  of  the  Unguals  in  the  neck. 
Some  bleeding  still  occurs  on  the  stump,  especially  if  the  tongue 
is  divided  far  back.  This  comes  from  the  dor.salix  lingmc  branches, 
which   are  not  shut  off  by  the  ligature,  and  from   small  anastoraos- 


THE   TONGVE.  105 

ing  vesseJs  of  the  ascending  pharyngeal  and  the  tonsiUar  branches 
of  the  facial  arteries.  Bleeding  from  the  stump  can  be  arrested,  and 
the  stump  brought  well  up  to  view,  by  pressing  up  the  floor  of  the 
mouth  by  the  fingers  apj)lied  between  the  jaw  and  the  hyoid  bone. 
If  the  operation  is  limited  to  one  aide  it  is  only  necessary  to  ligate  the 
lingual  on  that  side,  for  there  is  but  little  anastomosis  across  the  rather 
incomplete  median  fibrous  septum  of  the  tongue.  The  two  ranine 
arteries  anastoiaosc  by  a  small  loop  near  the  tip  of  the  tongue,  other- 
wise only  by  capillary  branches,  except  in  the  rare  cases  where  the 
principal  part  of  both  Unguals  are  given  off  from  one  side.  In  the 
latter  case  ligature  of  the  small  vessel  on  the  other  side  would  not 
prevent  copious  bleeding  on  that  side. 

The  following  strnctarcx  are  divided  in  an  excision  of  the  entire  tongue  : 
the  mucous  membrane  connecting  the  tongue  with  the  jaw  the  epiglottis 
and  the  soft  palate ;  the  genio-,  hyo-,  stylo-,  and  palatoglossi  and  the 
Hngualis  muscles ;  the  lingual,  hypoglossal  and  glosso-pharyngeal  nerves 
and  the  lingual  vessels  and  their  anastomoses  (see  above).  In  Kocher's 
operation  a  flap  is  turned  up  helov:  the  jaic,  the  muscular  diaphragm  of  the 
mouth  (mylohyoid)  divided  and  the  mouth  then  entered  by  dividing  the 
mucosa  along  its  attachments  to  the  gums.  Through  the  same  incision 
anv  infected  sabina.vi/Jari/  Iijmph  nodes  may  be  removed,  the  Unrjual  artery 
tied  and  excellent  drainage  provided  to  guard  against  septic  aspiration 
pneumonia,  a  not  infrequent  cause  of  death  in  such  operations.  Wounds 
of  the  tongue  are  not  uncommon  and  may  require  suture.  I  have  seen 
a  case  where  a  child  bit  her  tongue  half  through  and  a  similar  accident 
had  occurred  in  two  previous  generations  of  the  family. 

As  a  consequence  of  the  raseidarifi/  of  the  tongue  it  is  often  the  seat 
of  nsevoid  growths.  The  lingual  arteries  (averaging  3  mm.  in  caliber) 
pass  upward  and  forward  to  the  base  of  the  tongue  beneath  the  hyo- 
glossus  muscle,  in  front  of  Avhich  they  run  forward  as  the  ranine  arte- 
ries near  the  under  surface  of  the  tongue.  They  are  often  brittle, 
especially  at  the  age  when  cancer  is  prevalent.  Cancer  tends  to  ex- 
tend toward  the  best  blood  supply,  hence  lingual  cancer  tends  to  spread 
downward  toward  the  root  of  the  tongue,  which  is  also  the  course  of 
the  lymphatics.  The  lymphatics  of  the  tongue  are  large,  numerous 
and  important  in  connection  with  the  nodular  infection  which  occurs 
early  in  lingual  cancer.  The  lymphatics  of  the  fore  part  of  the  tongue 
enter  the  submaxillary  nodes  ;  those  of  the  back  part  enter  some  small 
lingual  nodes  on  the  hypoglossus  muscle  and  thence  jmss  to  the  deep 
cervical  nodes.  The  lymphatics  for  the  most  part  follow  the  blood 
vessels  of  the  tongue.  The  enlargement  of  the  tongue  in  the  strange 
congenital  condition  known  as  macroglossia  is  due  principally  to  a  great 
dilatation  of  the  lymph  eliannels  (/iinijihanf/ionia)  and  to  an  increase  of 
the  lymph  tissue  throughout  the  tongue.  In  some  cases  it  reaches  a 
prodigious  size,  filling  and  projecting  far  out  of  the  mouth  and  deform- 
ing the  teeth  and  alveolar  arches  by  pressing  them  forward.  The  base 
of  the  tongue  is  the  part  most  atfected.  Excision  by  a  wedge-shaped 
incision  or  the  use  of  the  cautery  sometimes  gives  a  good  result. 


106  THE  HEAD  AND  NECK. 

Nerves  of  the  Tongue. — The  hypoglossal  supplies  the  mumles  of 
the  tongue,  though  the  chorda  tytnpani  may  carry  some  motor  fibers 
from  the  facial.  The  chorda  tympani,  carrying  fibers  from  the  glosso- 
pharyngeal nucleus,  supplies  taste  fibers  to  the  anterior  two  thirds  of 
the  tongue ;  the  glossopharyngeal  nerve  supplies  taste  and  sensory 
fibers  to  its  posterior  third.  The  lingual  or  gustatory  nerve  supplies 
sensation  to  the  anterior  two  thirds  of  the  tongue,  in  which  the  sense  of 
touch  is  more  acute  than  in  any  other  part  of  the  body  and  is  used  by 
dealers  in  precious  stones  when  the  eye  alone  cannot  be  trusted.  This 
nerve  is  not  infrequently  affected  by  neuralgia  or  responsible  for  reflex 
symptoms  in  painful  affections  of  the  tongue,  which  are  most  common  in 
the  anterior  two  thirds  of  the  organ.  Neuralgia  of  this  nerve  in  can- 
cer of  the  tongue  is  sometimes  so  severe  as  to  demand  its  division  or 
excision.  By  pulling  the  tongue  forward  and  to  the  opposite  side  the 
nerve  may  be  made  prominod  by  its  elevating  a  ridge  of  mucous  mem- 
brane on  the  floor  of  the  mouth,  between  the  tongue  and  the  alveolar 
arch.  The  nerve  may  be  excised  after  dividing  the  mucous  membrane 
along  this  ridge,  except  in  cases  where  the  tongue  is  much  enlarged  and 
fixed  by  cancer.  This  is  better  than  merely  cutting  the  nerve,  as  may 
be  done  by  lloore's  method,  about  half  an  inch  from  the  last  molar 
tooth  at  the  point  where  it  crosses  the  line  from  that  tooth  to  the  angle 
of  the  jaw,  the  knife  being  entered  three  quarters  of  an  inch  behind 
and  below  the  tooth  down  to  bone  and  the  incision  carried  towards 
the  tooth. 

In  painful  affections  of  the  fore  part  of  the  tongue  the  p«m  is  often 
referred  to  other  branches  of  the  third  division  of  the  fifth  nerve,  pro- 
ducing pain  in  the  auditory  meatus  or  a  spasmodic  contraction  of  the 
muscles  of  mastication.  After  the  lingual  nerve  has  passed  forward 
from  between  the  ramus  and  the  internal  pterygoid  muscle  it  runs  be- 
neath the  mucous  membrane,  5  mm.  from  its  reflection  from  the  side  of 
the  tongue  and  then  beneath  the  sublingual  gland,  \\\\\\\i\v^.vion^9>  duct. 
It  can  be  readily /e/^  by  the  finger  pressed  against  the  inner  surface 
of  the  jaw  in  a  direction  downward  and  backward  from  the  last  molar 
tooth.  Branches  of  the  superior  laryngeal  nerve  reach  the  root  of  the 
tongue  near  the  e})igl()ttis. 

The  part  of  the  floor  of  the  mouth  between  the  tongue  and  the  alve- 
olar arch  is  covered  by  mucous  membrane,  reflected  from  the  tongue 
to  the  gums,  and  is  divided  into  two  symmetrical  halves  by  the  frrenum 
of  the  tongue.  On  either  side  of  the  latter  are  two  well-marked  ridges 
directed  backward  and  outward,  due  to  the  presence  of  the  sublingual 
gland.  Along  these  ridges  the  ten  to  twenty  ducts  of  the  gland  open 
and  at  the  anterior  ends  of  the  ridges,  on  either  side  of  the  frsenum,  we 
notice  the  papilhv.  on  which  arc  the  orifices  of  Wharton's  duct.  The 
duct  of  Bartholin,  from  a  group  of  lobes  of  the  sublingual  gland,  opens 
with  or  near  Wharton's  duct. 

Wharton's  duct  passes  obliquely  forward  and  inward  for  5  cm.  from 
the  deep  lobe  of  the  submaxillary  gland,  near  the  posterior  border  of 
the  mylohyoid.      It  accompanies  the  lingual  nerve,  crossi))g  (djove  the 


THE  PALATE.  107 

latter,  wliich  inclines  inward  to  the  tongue,  and  it  lies  beneath  and 
behind,  or  internal  to,  the  sublingual  gland.  Its  walls  are  thin  but  not 
distensible  so  that  when  it  becomes  blocked  by  an  impacted  calculus  the 
jjuin  from  tension  is  intense  as  it  cannot  become  rapidly  or  largely  dilated 
to  form  a  cystic  tumor. 

Such  a  cystic  tumor  is  known  as  ranvila,  a  term  applied  to  cysts  of 
varied  origin  filled  with  mucous  contents  and  situated  under  the 
tongue  or  in  the  floor  of  the  mouth.  Typical  ranula  is  a  retention  cyst 
of  the  mucous  glands  ;  according  to  Recklinghausen  most  frequently 
of  those  that  lie  beneath  the  tip  of  the  tongue.  Other  cysts  in  this 
situation  are  classed  as  ranula,  including  retention  cysts  of  the  sub- 
lingual gland  ducts  or  of  Wharton's  duct. 

The  presence  of  Fh'isclmann''s  sidjlinf/ual  bursa  is  denied  by  most 
authorities,  but  according  to  Tillaux  it  is  the  seat  of  the  acute  or 
rapidly  formed  ranula,  which  sometimes  occurs.  Tillaux  describes  it 
as  follows.  It  is  triangular  in  form,  situated  between  the  genio- 
glossus  muscle  and  the  mucous  membrane  which  is  reflected  from 
beneath  the  front  and  sides  of  the  tongue  to  the  floor  of  the  mouth. 
Its  apex  lies  at  the  end  of  the  frsenum  on  the  under  surface  of  the 
tongue  and  its  base  at  the  sublingual  gland,  which  separates  the  mucosa 
from  the  srenioslossus  muscle.  It  is  constricted  in  its  center  by  the 
frsenum  and  reaches  back  on  either  side  to  the  first  or  second  molar 
tooth.  Incision  alone  will  not  cure  a  ranula,  for  after  the  incision 
heals  the  cyst  refills.  Its  lining  membrane  must  be  dissected  out  as 
far  as  possible  and  the  edges  of  what  is  left  sutured  to  the.  opening 
in  the  mucous  membrane. 

Congenital  dermoid  or  branchiogenic  cysts  in  the  floor  of  the  mouth, 
between  the  tongue  and  the  lower  jaw,  may  resemble  ranula.  They 
are  due  to  the  imperfect  closure  of  the  first  branchial  cleft  or  arch. 
Cysts  or  solid  tumors  deeply  seated  in  the  tongue  or  in  the  vicinity  of 
the  hyoid  bone  may  develop  from  the  thyroglossaJ  duct,  leading  from 
the  foramen  ceecum.  In  this  manner  ]3robably  some  of  the  deep-seated 
forms  of  cancer  and  cancerous  cysts  of  the  neck  are  formed. 

When  the  mouth  is  widely  opened  the  pterygomaxillary  ligament 
can  be  readily  _/V//  beneath  the  mucous  membrane  and  can  be  seen  as  a 
prominent  fold  running  obliquely  downward  behind  the  last  molar 
teeth.  The  loose  connective  tissue  in  the  floor  of  the  mouth  between 
the  mylohyoid  muscle  and  the  mucous  membrane,  together  with  that 
in  the  submaxillary  region,  is  involved  in  the  septic  inflammation 
known  as  Ludwig's  angina. 

The  Palate. — The  hard  palate  separates  the  mouth  from  the  nose, 
hence  when  it  is  cleft  these  two  cavities  communicate.  Its  form  is 
determined  by  that  of  the  horseshoe-shaped  alveolar  arch  which 
borders  it.  Normally  the  greatest  width  about  equals  its  length,  but 
this  relation  varies  widely.  Normally  it  presents  a  flat  arcli,  abnor- 
mally a  high  and  narrow  one.  The  latter  form  is  said  to  be  common 
in  congenital  idiots  and  often  occurs  in  the  two  halves  of  a  cleft  j>alate, 
especially   in  complete  clefts.     This   is   a  fact   of  importance  in  the 


108  THE  HEAD  AJSD  NECK. 

closure  of  the  cleft,  for  in  such  cases  the  flaps,  when  brought  down  to  a 
more  horizontal  position,  are  ample  to  meet  and  be  sutured  in  the 
median  line.  These  flaps  consist  of  the  entire  soft  parts  which  cover 
the  bony  framework  and  are  composed  of  a  firm  pale  mucosa  fused 
with  the  periosteum  so  that  they  can  not  be  separated.  This  dense, 
tough  muco-periosteum  is  thickened  by  the  many  glands  contained 
between  its  two  layers  except  in  the  median  line.  Posterior  to  the 
anterior  palatine  foramen  a  median  raphe  indicates  the  formation  of 
the  palate  from  two  lateral  halves). 

The  muco-periosteum  is  supplied  principally  by  the  posterior  pala- 
tine artery  which  lies  near  its  deep  surface  and  passes  forward,  at  the 
junction  of  the  palate  and  the  alveolar  process,  from  the  lower  opening 
of  the  posterior  palatine  canal,  internal  to  the  last  molar  tooth.  The 
two pi'inclpal  dangers  of  operations  for  the  closure  of  a  cleft  of  the  hard 
palate  are  hemorrhage  and  gangrene  of  the  flaps,  both  due  to  a  division 
of  the  posterior  palatine  artery  or  its  branches  which  pass  inward  to 
supply  the  muco-periosteum.  Hence  this  division  should  be  avoided 
and  the  artery  and  its  branches  pjreserved  in  the  flap  for  its  nourish- 
ment by  making  the  lateral  incision,  bordering  the  flap,  along  the  base 
of  the  alveolar  process,  outside  the  course  of  the  artery.  The  nerves 
come  from  Meckel's  ganglion. 

The  soft  palate  is  of  about  the  same  length  as  the  hard  palate  but 
it  is  broader  than  it  is  long,  and  about  one  quarter  of  an  inch  thick. 
Its  sides  are  merged  into  the  pharyngeal  wall.  The  anterior  third  of 
the  soft  palate  contains  the  palate  aponeurosis  which  is  always  ^zrm  and 
tense  so  that,  as  it  is  continuous  in  position  and  direction  with  the  hard 
palate,  it  is  often  hard  to  distinguish  it  from  the  latter  by  the  touch, 
as  in  passing  a  Eustachian  catheter  (see  p.  58).  The  aponeurotic 
portion  does  not  share  in  the  movements  of  the  posterior  or  muscular 
portion  of  the  soft  palate.  The  tendon  of  the  tensor  pcdati  muscle  is 
connected  with  this  aponeurosis  which  is  already  tense  and  can  scarcely 
be  made  much  more  so.  Indeed  it  is  probable  that  the  principal  action 
of  this  muscle,  certainly  of  those  fibers  attached  to  the  fibrous  portion 
of  the  Eustachian  tube,  is  to  open  that  tube.  Such  an  opening  occurs 
wdienever  the  palate  is  raised,  as  in  swallowing,  and  on  this  fact  de- 
pends the  Pollitzer  method  of  inflating  the  middle  ear  (see  p.  57). 

The  levator  palati  and  azygos  uvulce  muscles  were  formerly  thought 
to  be  supplied  by  the  facial  nerve,  through  the  great  superficial  petrosal 
and  Meckel's  ganglion,  and  hence  to  be  affected  by  paralysis  of  the 
facial  nerve  when  the  lesion  is  mesial  to  the  geniculate  ganglion.  It 
is  questionable  whether  this  is  the  source  of  their  nerve  supply  which 
is  now  traced  through  the  pharyngeal  plexus  from  the  spinal  accessory 
nerve.  These  two  muscles  are  embraced  in  the  palate  by  the  two 
heads  or  layers  of  the  palafopJtaryngeus.  The  fibers  of  the  pahdo- 
glosHUH  form  the  most  inferior  layer  of  those  which  make  uj)  the  sub- 
stance of  the  soft  palate.     * 

All  the  muscles  named,  except  the  azygos  uvuhe,  join  those  of  the 
opposite  side  in  the  median  line  and  hence  by  their  contraction  tend  to 


THE  SOFT  PALATE.  109 

widen  a  deft  of  the  palate  ov  pull  apart  the  sutures  introduced  to  close 
it.  According  to  some  the  levator  and  tensor  palati  are  the  chief 
agents  drawing  asunder  the  sutured  cleft.  To p recent  this  interference 
with  the  success  of  the  operation  many  resort  to  free  antero-])osterior 
incixions  through  the  palate  along  the  side  of  each  half,  to  divide  the 
muscles.  In  place  of  this  a  tenotomij  of  one  or  more  muscles,  espe- 
cially the  levator  palati  and  palatopharyngeus,  has  been  employed  by 
others.  Billroth  broke  ojf' the  liamular  process  and  displaced  it  inward 
together  with  the  tensor  palati  tendon  which  winds  around  it,  in  order 
to  relax  the  latter,  with  good  results.  The  hamular  j)rocesscan  ha  felt 
to  the  inner  side  and  behind  the  last  upper  molar  tooth.  Woltf  thinks 
the  soft  palate  is  best  relaxed  by  separating  the  muco-periosteum  from 
the  bony  hard  palate  as  in  operations  to  close  clefts  of  the  latter.  In 
any  case  the  aponeurosis  must  be  freed  from  its  attachment  to  the  pos- 
terior border  of  the  bony  hard  palate  to  allow  the  anterior  part  of  the 
soft  palate  to  come  together  readily. 

The  posterior  t-wo  thirds  of  the  soft  palate,  the  portion  behind  its 
aponeurosis,  forms  tiie  velum  pendulum  palati  proper  or  the  movable 
curtain  which  in  breathing  through  tlie  nose  hangs  down  in  the  isth- 
mus of  the  fauces  and  shuts  off  the  mouth  from  the  pharynx,  and  in 
deglutition  or  breathing  through  the  mouth  is  raised  to  a  horizontal 
position  to  shut  off  the  buccal  portion  of  the  pharynx  from  the  naso- 
pharynx, to  prevent  food  entering  the  latter  in  swallowing.  Hence  in 
paralysis  of  the  palate,  as  sometimes  occurs  after  diphtheria  and  from 
other  causes,  the  palate  can  not  be  raised,  the  nasopharynx  is  not  shut 
off  and  fluids  are  liable  to  regurgitate  through  the  nose.  The  elevation 
of  the  palate  during  breathing  througli  the  mouth  is  taken  advantage 
of  in  one  form  of  nasal  irrigation  (see  p.  80).  When  the  palate  is 
elevated  it  is  enabled  to  shut  oflP  the  buccal  from  the  nasal  portion  of 
the  pharynx  by  the  contraction  of  the  superior  constrictor  muscle  which 
narrows  this  part  of  the  pharynx  and  brings  forward  its  posterior  wall. 

The  azygos  uvulaj  passes  into  the  uvula  and  by  its  contraction 
shortens  and  raises  it.  Elongation  of  the  uvula  is  largely  due  to 
hypertrophy  of  the  part  near  the  tip,  beyond  the  muscle.  When 
elongated  it  may  touch  the  base  of  the  tongue  or  produce  cou^diino- 
in  the  supine  position  by  irritating  the  back  wall  of  the  pharynx. 
It  may  be  readily  snipped  off  if  necessary.  From  the  base  of  the 
uvula  two  folds  of  mucous  membrane  pass  off  on  either  side  in  an  out- 
ward and  downward  direction,  the  anterior  and  jxistcrior  pillars  of  the 
fauces.  The  anterior  folds  cover  the  palatoglossi  and  incline  forward. 
The  space  between  them  forms  the  isthmus  of  the  fauces,  the  opening 
between  the  mouth  and  the  pharynx,  and  i6h(*und(d  bv  tiie  tongue  be- 
low and  by  the  palate  above.  In  deglutition,  after  the  food  is  passed 
into  the  pharynx,  the  isthmus  is  closed  i)y  the  contraction  and  ajiproxi- 
mation  of  its  pillars  and  the  elevation  of  the  back  of  the  tongue  to 
the  palate,  to  shut  off  the  mouth  from  the  pharynx.  The  posterior 
folds  cover  the  palatopharyngei  and  incline  somewhat  backward.  As 
the  latter  approach  nearer  to  one  another  than  tiie  anterior  piHarstiiey 


110  THE  HEAD  AND   XECK 

are  readily  seen  behind  them.     Between  the  two  pillars  of  each  side 
lie  the  tonsils  (see  p.  111). 

The  blood  supply  of  the  soft  palate  is  derived  from  the  ascending 
palatine  branch  of  the  facial,  the  palatine  branch  of  the  ascending 
pharyngeal  artery  and  the  descending  palatine  branch  of  the  internal 
maxillary.  The  lymphatics  of  the  palate  enter  the  internal  maxillary 
or  deep  facial  nodes,  on  the  side  of  the  superior  constrictor  just  behind 
the  pterygomaxillary  ligament,  and  thence  pass  to  the  deep  cervical 
nodes.  The  sensory  nerves  come  from  Meckel's  ganglion  and  the 
glossopharyngeal.  The  latter  nerve  probably  supplies  the  scattered 
taste  buds  found  on  the  under  surface  of  the  palate.  The  terms  pala- 
table, to  tickle  the  palate,  etc.,  are  not  without  physiological  founda- 
tion in  fact,  though  the  tongue  is  the  principal  organ  of  taste. 

Development  (see  also  p.  99). — The  palate  is  formed  by  the  junction 
in  the  middle  line  of  the  palatal  processes  of  the  superior  maxillary 
processes  which  grow  backward  and  inward  to  separate  the  mouth 
from  the  nose.  This  union  begins  in  front  about  the  eighth  week  of 
f(]etal  life  and  is  completed  posteriorly  in  the  ninth  and  tenth  weeks. 
Throughout  the  hard  palate  this  line  of  union  is  joined  from  above  by 
the  frontonasal  process,  forming  the  septum  of  the  nose,  to  the  lower 
and  anterior  angle  of  which  are  attached  the  intermaxillary  bones. 
These  bones  join  the  palate  processes  of  the  maxiilre  along  suture  lines 
passing  forward  and  outward  from  the  anterior  palatine  foramen  to  the 
interspace  between  the  canine  and  lateral  incisors  of  each  side,  so  that 
they  contain  the  four  incisor  teeth. 

Congenital  cleft  palate  is  an  error  of  development,  a  failure  of  fusion 
of  the  parts  of  which  the  palate  is  formed.  In  the  soft  pa/ate  the  clefi 
is  median  and  single;  in  the  hard  palate,  as  far  forward  as  the  anterior 
palatine  foramen,  it  is  nearly  or  quite  median  in  position  but  is  called 
unilateral  or  bilateral  according  as  one  or  both  palatal  processes  fail  to 
join  the  vomer,  which  is  formed  by  the  median  frontonasal  process. 
If  the  cleft  is  unilateral  it  communicates  with  the  nasal  fossa  of  one 
side,  if  bilateral  with  both  nasal  fossse  and  the  free  border  of  the  vomer 
appears  in  or  above  the  cleft.  In  one  case  I  observed  entire  absence  of 
the  nasal  septum,  which  occurs  occasionally.  In  front  of  the  anterior 
palatine  foramen  the  cleft  in  extending  through  the  alveolar  border  is 
always  unilateral  or  bilateral,  never  median.  If  the  cleft  is  bilateral 
the  intermaxillary  bones  are  entirely  separate  from  the  maxillse  and, 
supported  on  the  end  of  the  nasal  septum,  they  often  protrude  forward 
and  appear  to  be  suspended  from  the  end  of  or  beneath  the  nose.  Such 
forms  are  usually  accompanied  by  a  double  harelip ;  the  unilateral 
cleft  of  the  alveolar  process  is  as  a  rule  associated  with  a  single  hare- 
lip, occasionally  with  a  double  one.  In  unilateral  clefts  the  alveolar 
process  of  the  intermaxillary  bones  may  be  on  a  line  with  the  alveolar 
process  across  the  cleft  or  it  may  project  in  front  of  it. 

According  to  Kolliker  and  others,  the  cleft  in  the  lip  and  alveolar 
process  is  between  the  frontonasal  process  and  the  superior  maxillary 
process,  i.  e.,  between  the  intermaxillary  bones  and  the  maxilla  or 


PLATE    VI  r 


FIG.  26. 


lOR     PA  LA- 
FOSSA 


PREMAXILLARY 
SUTURE 


POSITION    OF    LATERAl 
CLEFT    OF    HARD 
PALATE 


DESCENDING    PALA- 
TINE   ARTERY 


Hard    palate,   showing    the   course    of  the    arteries  and  of 
the  lateral  clefts.     (Modified  from  Merkel.) 


FIG.  27. 


INT.   JUGU- 
LAR   VEIN     INT.    CAROTID 
ARTERY 


-f 


LONGUS    COLLI 
MUSCLE 


TEMP-MAXILLARY    VEIN 
PAROTID 
EXT.   CAROTID    ARTERY^ 
STYLO-HYOID  &.  STYLO- — 

PHARYNG.    MUSCLES 
PHARYNGO-MAXILLARY 
SPACE 

INT.    PTERYGOID     MUSC 

INF.     DENTAL    FORAMEN 

RAMOS 

MASSETER 

FACIAL    ARTERY 


LYMPH     NODE 

PALATO-PHARYNGEUS 

MUSCLE 
SUP.    CONSTRICTOR    M. 
"TONSIL 
PALATO-GLOSSUS 

MUSCLE 
FORAMEN    C/ECUU 


Horizontal  section  through  the  commissure  of  the 
lips  and  the  tonsils.  The  section  passes  through  the 
odontoid  process  and  shows  the  pharyngo-maxillary 
space.     (Merkel.) 


THE  TONSILS.  HI 

between  the  lateral  incisor  and  canine  teeth.  But  Albrecht  regards  it 
as  between  the  frontonasal  and  the  lateral  frontal  processes.  lie  as- 
sumes four  intermaxillary  bones,  two  on  either  side,  and  holds  that  the 
cleft  is  between  the  two  of  either  or  both  sides,  that  is  between  the 
central  and  lateral  incisors.  His  views  have  been  largely  confirmed  by 
others.  Both  views  are  probably  correct  and  the  position  of  the  clefts 
is  not  alwavs  constant.  There  are  clefts  between  the  lateral  incisor  and 
canine  teeth,  others  between  the  lateral  and  central  incisors,  but  more 
often  the  lateral  incisor  is  wanting,  which  was  formerly  explained  by 
saying  that  it  was  "  lost  in  the  cleft."  In  bilateral  clefts  through  the 
alveolar  process  the  protruded  intermaxillary  bones  as  a  rule  contain 
the  germs  of  the  central  incisors  only. 

Cleft  palate  varies  greatly  in  extent.  Rarely  it  may  involve  the 
uvula  only  or  merely  the  middle  of  the  soft  palate.  A  cleft  of  the 
soft  palate  often  exists  without  any  in  the  hard  palate,  or  at  most  only 
in  the  posterior  part  of  it  ;  but  clefts  of  the  hard  palate  rarely  occur 
without  one  in  the  soft  palate.  In  rare  cases  the  intermaxillary  bones 
may  be  entirely  absent  and  the  coexisting  double  harelip  appears  as  a 
large  median  gap. 

Where  there  does  not  appear  to  be  enough  tissue  to  fill  the  gap  of 
a  cleft  palate  I  have  tried  with  excellent  results  the  plan  of  chiselling 
through  the  palate  processes  along  the  inner  border  of  the  alveolar 
process,  crowding  inward  the  former,  packing  the  gap  so  formed  to 
keep  the  palate  processes  in  their  new  position  and  after  six  or  eight 
weeks  completing  the  operation  in  the  usual  way. 

The  usual  operation  consists  in  broadly  freshening  both  edges,  dissect- 
ing up  afJap  of  inuro-periosteum  on  each  side  as  far  as  the  alveolar 
process,  where  it  is  limited  by  an  incision  along  the  base  of  the  proc- 
ess (p.  108),  and  then  bringing  together  and  suturing  tlie  edges. 
It  seems  better  to  treat  some  bad  clefts  of  the  palate  by  an  obturator 
fastened  to  the  six-year  molars.  Such  obturators,  if  well  made, 
give  an  excellent  functional  result  as  far  as  speech  and  swallow- 
ing are  concerned.  Infants  with  cleft  palate  can  usually  nurse 
from  a  bottle  if  a  large  nipple  is  used  which  fills  up  the  cleft. 
But  later  on  articulation  is  very  imperfect  and  the  voice  very  nasal 
in  tone. 

The  tonsils  are  lymphoid  masses  situated  in  the  triangular  recesses 
between  the  pillars  of  the  fauces  and  the  base  of  the  tongue.  The 
floor  of  this  recess  is  formed  by  the  pharyngeal  aponeurosis  and  the 
superior  constrictor  muscle,  on  which  each  tonsil  rests  and  by  which 
it  is  separated  from  the  pharyngomaxillary  space.  The  latter  lie.s  be- 
tween the  lateral  wall  of  the  pharynx  internally,  the  internal  ptery- 
goid muscle  externally  and  the  upper  cervical  vertebra?  posteriorly  and 
contains  fat  and  loose  cellular  tissue.  Zuckerkandl  sh(»wed  that  it  was 
divided  by  the  styloglossus  and  styl(>i)haryngrus  inusclos  into  an 
anterior  chamber,  contiguous  to  the  tonsil,  and  a  posterior  chamber  con- 
taining in  its  hindermost  part  the  internal  carotid  artery  the  internal 
jugular  vein  and  their  accompanying  nerves.     (Fig.  27.) 


112  THE  HEAD   AND  NECK. 

Quinsy,  which  is  a  peritonsillitis  or  an  inflammation  around  the 
tonsil,  is  confined  in  most  cases  to  the  anterior  chamber  of  this  space 
and  only  rarely  extends  to  the  posterior  chamber,  in  which  case  the 
internal  carotid  might  possibly  become  eroded  as  reported  in  a  few 
cases.  The  peritonsillar  inflammation  in  the  anterior  chamber  meets 
no  obstacle  in  extending  outward  as  far  as  the  internal  pterygoid 
muscle,  but  then  further  swelling  projects  inward  toward  the  mouth  in 
the  line  of  least  resistance. 

A  quinsy  is  v.^iia////  opened  through  the  soft  palate  just  above  the 
tonsil  and  the  wounding  of  the  internal  carotid  is  out  of  the  question 
for  in  the  adult  it  lies  3  cm.  behind  this  point  in  the  normal  state  and 
probably  twice  as  far  when  the  parts  are  bulged  forward  by  the  in- 
flammation. In  children  the  distance  is  relatively  even  greater,  though 
of  course  actually  somewhat  less.  As  the  internal  carotid  is  at  least 
1.5  to  2  cm.  behind  the  tonsil  there  is  even  less  danger  of  its  being 
wounded  in  tonsillotomy  for  no  puncture  is  then  made.  A  wound  of 
the  artery  has  probably  never  occurred  from  tonsillotomy  or  opening 
a  peritonsillar  abscess,  though  several  cases  are  recorded  where  the 
artery  has  become  eroded  in  a  peritonsillar  inflammation.  It  is  in 
operations  on  the  lateral  aspect  of  the  pharynx  that  the  internal  caro- 
tid is  in  danger  of  being  wounded. 

The  external  carotid  artery,  2  cm.  from  the  lateral  perijihery  of  the 
tonsil,  is  still  more  out  of  the  way,  lying  external  to  the  muscles  aris- 
ing from  the  styloid  j^rocess.  The  ascending  pharyngeal  artery  is 
nearer  the  tonsil  than  the  internal  carotid,  and  gives  a  branch  to  it, 
but  lies  behind  it  in  the  pharyngomaxillary  space  and  its  main  trunk 
is  not  exposed  to  injury  in  tonsillotomy.  In  one  of  the  very  few 
cases  where  fatal  bleeding  followed  this  operation  the  tonsillar  branch 
of  the  facial  was  proved  to  be  the  source  of  hemorrhage.  Bleeding 
from  the  ascending  pharyngeal  artery  has  proved  fatal  in  a  case  re- 
ported l)y  Mr.  INIorrant  Baker,  but  it  did  not  follow  tonsillotomy  but  a 
wound  due  to  a  pipe  stem  driven  through  the  tonsil.  According  to 
Merkel  the  source  of  severe  arterial  honorrhage  after  tonsillotomy,  etc., 
is  in  most  cases  the  faded  artery  which,  as  it  passes  between  the 
digastric  and  styloglossus  muscles,  may  take  a  sharp  S-shaped  bend, 
which  comes  very  close  to  the  lateral  surface  of  the  tonsil. 

The  position  of  the  tonsil  corresponds  superficially  to  the  angle  of 
the  jaw  but,  owing  to  the  intervening  structures,  enlargement  of  the 
tonsil  other  than  malignant  cannot  be  felt  externally.  AYhat  is  felt 
and  mistaken  for  the  tonsil  is  an  enlargement  of  the  lymph  nodes  here 
which  regularly  accompany  affections  of  the  tonsil.  Enlarged  or  hjiper- 
tropjliied  tonsils  project  in  the  line  of  least  resistance  toward  the  median 
line  where  they  may  even  meet  and  cause  difficulty  in  swallowing.  As 
the  projecting  mass  of  hypertrophied  tonsils  also  narrows  the  pharyn- 
geal passageway  between  the  nose  and  the  larynx  the  subject  of  such 
hypertrophy  sleeps  with  the  mouth  open,  to  get  more  air,  and  usually 
snores.  The  throat  therefore  becomes  dry  and  inflamed.  In  such 
cases  the  chest  is  badly  developed,  from  insufficient  suj)])ly  of  air,  and 


THE  PHARYNX.  113 

becomes  i)igeon-breasted  if  the  subject  has  rickets.  The  nose  is  also 
small  and  flattened,  as  little  air  passes  through  it,  and  the  voice  is 
thick. 

As  the  Hoft  palate  intervenes  between  the  ton»il  and  the  EuHtachian 
tube  the  deafness  coni[)lained  of  in  such  cases  is  not  due  to  direct 
pressure,  which  is  anatomically  impossible,  but  to  a  coexidincj  hyper- 
trophy of  the  adenoid  tissue  about  and  within  the  Eustachian  tube.  It 
is  possible,  however,  that  the  hypertrophied  tonsil  by  pressing  up  the 
soft  palate  may  relax  the  tensor  tympani  muscle  and  thus  hinder  its 
opening  the  tube. 

In  the  inflammation  known  as  folficalar  ton.si/lifis  the  openings  of  the 
twelve  or  fifteen  crypts  on  the  free  internal  surface  of  the  tonsil  are 
filled  with  a  yellowish-white  deposit  composed  of  desquamated  epi- 
thelium, leucocytes,  bacteria,  etc.  The  decomposition  of  retained 
epithelial  structures  and  food  debris  within  the  crypts  of  an  enlarged 
tonsil  may  give  rise  to  foul  breath  and  to  the  repeated  attacks  of  in- 
flammation to  wdiich  such  tonsils  are  liable.  The  attachment  of  the 
tonsil  to  the  muscles  of  the  pharynx  renders  deglutition  jjainful  in  acute 
inflammations  of  the  tonsil  because  of  the  movements  conveyed  to  the 
latter  by  the  movements  of  the  pharynx.  Thus  the  superior  constric- 
tor moves  it  inward  and  the  stylopharyngeus  outward.  The  action  of 
the  latter  in  drawing  the  tonsil  outward,  combined  with  a  prominent 
anterior  faucial  pillar  may  make  it  difficult  to  reach  the  tonsil  with  the 
tormllotome .  The  latter  should  be  introduced  backward  and  slightly 
downward,  for  this  is  the  direction  of  the  long  axis  of  the  tonsil,  -which 
normally  measures  about  one  inch.  Its  postero-inferior  end  is  some- 
times hard  to  inspect. 

Although  the  blood  supply  is  from  multiple  sources  the  uninflamed 
tonsil  is  not  very  vascular  so  that  it  often  bleeds  but  little  on  removal, 
but  it  may  give  rise  to  troublesome  hemorrhage  if  removed  when  in- 
flamed. The  arterial  supply  comes  from  the  tonsillar  and  ascending 
palatine  branches  of  the  facial,  the  descending  palatine  branch  of  the 
internal  maxillary,  the  dorsalis  linguae  branch  of  the  lingual  and 
branches  of  the  ascending  pharyngeal.  The  veins  form  the  tonsillar 
plexus  on  the  outer  side  of  the  gland,  which  joins  the  ]iharyngeal 
plexus.  The  lymphatics  of  the  tonsil  enter  the  submaxillary  nodes 
near  the  angle  of  the  jaw,  which  are  usually  involved  in  afl'ections  of 
the  tonsil  and  may  be  readily  felt.  The  nerves  come  from  ^Meckel's 
ganglion  and  the  glossopharyngeal  nerve.  The  latter  as  it  winds 
around  the  palatopharyngeus  is  in  such  close  relation  to  the  tonsil  as 
to  be  in  some  danger  of  injury  in  operations  on  or  about  the  tonsil. 

The  tonsil  is  not  infrequently  the  seat  of  malignant  new-groirths^ 
sarcoma  and  epithelioma,  on  account  of  which  it  is  removed  with  a 
wide  margin  of  healthy  tissue,  either  through  the  mouth,  after  splitting 
the  cheek  or  dividing  the  jaw,  or  through  the  neck  by  a  lateral 
pharyngotomy. 

The  pharynx  extends  from  the  basilar  process  of  the  occipital  bone 
to  the  lower  part  of  the  cricoid  cartilage,  which  is  opposite  the  sixth 
8 


114  THE  HEAD  AND  NECK. 

cervical  vertebra,  when  the  neck  is  neither  flexed  nor  extended.  It  is 
4|  inches  Jong,  much  wider  transversely  than  antero-posteriorly,  widest 
opposite  the  hyoid  bone  (about  If  inches)  and  luirroirexi  (14  mm.)  at 
tlie  lower  end  where  it  is  continuous  with  the  oesophagus.  Hence  foreign 
bodies  which  reach  the  pharynx  are  most  likely  to  be  arrested  at  the 
latter  point  which  is  a  little  beyond  the  reach  of  the  finger,  for  it 
measures  six  inches  from  the  incisor  teeth.  The  latter  measurement 
should  be  remembered  in  passing  oesophageal  bougies  to  determine  the 
position  of  a  stricture,  and  it  should  be  added  to  the  length  of  the 
oesophagus  (9^  inches)  to  determine  the  distance  from  the  teeth  to  the 
stomach. 

The  variety  of  foreign  bodies  reported  as  arrested  in  the  pharynx 
is  very  great.  Perhaps  the  most  common  are  large  masses  of  food 
swallowed  gluttonously,  a  frequent  occurrence  among  the  insane. 
Treves  cites  a  case  reported  by  Dr.  Geoghegan  where  a  tooth  plate 
containing  five  teeth  and  surrounding  five  others  was  lodged  in  the 
pharynx  for  five  months  and  caused  trouble  which  was  first  supposed 
to  be  cancerous.  Stones,  coins,  etc.,  are  also  arrested  here  and  strang- 
est of  all,  live  cat  fish  are  said  to  have  jumped  into  the  mouths  of 
bathers  in  India  and  to  have  become  impacted  in  the  fauces.  When 
the  foreign  body  is  a  large  one  it  may  block  the  laryngeal  opening  and 
thereby  cause  suffocation.  As  corrosive  ft  aids  pass  the  narrowest  point 
more  slowly  than  the  wider  parts  the  corrosive  action  is  more  intense 
and  the  resulting  cicatricial  contraction  more  marked  at  the  lower  end 
of  the  pharynx  than  it  is  above. 

The  pharynx  is  complete  behind  and  at  the  sides,  where  its  musculo- 
membranous  walls  separate  it  from  the  surrounding  parts.  It  is  in- 
complete in  front  where  it  presents  the  openings  of  the  posterior  nares 
above,  the  faucial  opening  into  the  mouth  below  and  still  lower  the 
upper  orifice  of  the  larynx.  The  froid  of  the  ])harynx  is  held  wide 
open  by  its  attachment  to  the  following  fixed  points,  the  internal  ptery- 
goid plate,  mandible,  hyoid  bone  and  thyroid  and  cricoid  cartilages. 

Relations  of  the  Pharynx. — The  posterior  wall  of  the  pharynx  is 
in  front  of  the  bodies  of  the  up])er  five  cerfical  rerte/jrrc.  The  anterior 
arch  of  the  atla.s  is  on  a  feref  tinth  the  j)(date,  and  behind  the  mouth  one 
can  palpate  the  anterior  surface  of  the  bodies  of  the  second  and  third 
cervical  vertebrae,  and  in  this  w^ay  determine  the  existence  of  a  fracture 
or  dislocation  of  these  vertebrae.  Owing  to  their  distance  from  the 
incisor  teeth  it  is  difficult  to  satisfactorily  palpate  the  fourth  and  fifth 
cervical  vertebrae.  Necrosed  portions  of  the  upper  cervical  vertebrae 
have  been  discharged  through  the  mouth. 

In  caries  of  the  upper  cervical  vertebrae,  which  is  most  common  in 
children,  a  retro-pharyngeal  abscess  may  form  in  the  loose  tissue  sepa- 
rating the  posterior  pharyngeal  wall  from  the  prevertebral  fascia.  A 
lipnph.  node  situated  in  this  loose  tissue  opposite  the  axis  receives  lymph 
vessels  from  the  hind  part  of  the  nasal  cavity,  the  roof  of  the  pharynx 
and  the  prevertebral  muscles,  and  may  also  be  the  starting  point  of 
such  an  abscess.     These  abscesses  may  push   forward  the   posterior 


RELATKjyS  OF   THE  I'll  ART  NX. 


115 


pharyngeal  wall  so  as  to  depress  the  soft  palate,  or,  if  they  extend 
further  downward,  they  may  cause  dyspncea  by  obstructing  the  open- 
ing into  the  larynx.  They  may  open  or  be  opened  through  the  mouth 
or  on  either  side  of  the  sternomastoid  after  passing  behind  the  great 
vessels  and  the  parotid  gland.  If  they  discharge  spontaneously  into 
the  pharynx  during  sleep  the  pus  may  be  inspired  and  cause  suffoca- 
tion or  set  up  a  septic  pneumonia.  Abscess  in  this  loose  retropfiari/n- 
(jedl  tissue  may  descend  along  the  a?soi)hagus  into  the  posterior  medias- 
tinum even  to  the  diaphragm.  This  loose  tissue  serves  the  purpose 
of  a  serous  cavity  and  allows  the  free  movements  of  the  pharynx. 


Fig.  28. 


EUSTACHIA 
TUBE 


THYBO-HYOID 
BURSA 


THYBO-HYOIO 

MEMBRANE 

THYRO-HYOIO 

MUSCLE 
FAT    IN     FRONT 
OF    EPIGLOTTIS 


THYROID    CAR- 
TILAGE 


SPHENOIDAL    SINUS 


PHARYNGEAL    TONSIL 
PHARYNGEAL    RECESS 


/.:y^;,\^\\  ANTERIOR    ARCH 
['■■'V   .    ,  \.-\\      OF    ATLAS 


AHYTENO-EPI- 
GLOTTIC    FOLD 


ARYTENOID 
MUSCLE 


Sagittal  section  of  tlie  pharynx,  etc.    (Zl'CKERKaxdl.) 

The  lateral  walls  of  the  pharynx  are  in  close  relation  with  the  //i^<'/-- 
nal  carotid  arteries  and  their  accompanying  nerves  (ninth,  tenth  and 
eleventh  and  sympathetic  nerves)  so  that  the  pulsations  of  the  artery 
may  be  felt  through  the  pharyngeal  wall  and  the  artery  may  be 
wounded  by  foreign  bodies  thrust  through  the  wall.  The  internal 
jugular  vein  is  less  exposed  to  injury  from  such  causes,  as  it  is  more 
laterally  placed.  The  >iti/loid  process  and  its  muscles,  the  inner  end  of 
the  jxirotid  (/land  and  the  upper  end  of  the  tin/roid  r/land  are  also  in 
relation  with  the  lateral  walls  of  the  pharynx.      If  (pifhelionui  involves 


116  THE  HEAD  AND  NECK. 

a  part  of  the  pharynx,  as  occasionally  happens,  with  or  without  inva- 
sion of  the  tonsil,  it  may  be  reached  through  an  incision  on  the  side  of 
the  neck.  In  such  cases  it  is  well  to  tie  the  external  carotid,  and,  in 
order  to  reach  the  upper  end  of  the  pharynx,  a  division  or  temporary 
resection  of  the  jaw  may  be  made.  The  loiver  end  of  the  pharynx  may 
also  be  reached  by  subhyoid  pharyngotomy  through  the  thyrohyoid  mem- 
brane, an  operation  which  also  exposes  the  portion  of  the  larynx  above 
the  glottis. 

The  nasopharynx,  or  the  upper  part  of  the  pharynx  which  is 
above  the  level  of  the  palate  and  behind  the  posterior  nares,  is  entirely 
respiratory  in  function.  Accordingly  its  epithelium  is  ci/iated  and  it  is 
shut  oif  from  the  lower  or  buccal  portion,  during  the  act  of  swallow- 
ing, by  the  elevation  of  the  soft  palate.  The  superior  constrictor  does 
not  reach  to  its  upper  end  at  the  sides  as  the  constriction  of  this  part 
serves  no  purpose.  The  space  above  the  curved  upper  border  of  the 
superior  constrictor,  the  sinus  of  3Iorgagni,  is  occupied  by  the  thick- 
ened upper  end  of  the  pharyngeal  aponeurosis,  which  lies  internal  to 
the  constrictor  muscles.  Through  this  space  pass  the  Eustachian  tube 
and  the  levator  palati  muscle.  In  Politzer's  method  of  inflating  the 
middle  ear  the  nasopharynx  is  shut  oflP  from  the  parts  below  by  the 
act  of  swallowing,  in  which  the  palate  is  raised,  so  that  the  air  forced 
into  the  nose  finds  no  exit  except  through  the  Eustachian  tube. 

The  nasopharynx  is  very  rich  in  lymphoid  or  adenoid  tissue  and  a 
mass  extending  around  its  posterior  wall  between  the  orifices  of  the 
Eustachian  tubes  is  known  as  the  pharyngeal  orLuschka's  tonsil,  which 
is  often  hypertrophied.  Reaching  from  this  point  forward  the  mucosa 
of  the  roof  and  upper  part  of  the  pharynx  is  rich  in  similar  tissue  which, 
when  hypertrophied,  gives  rise  to  nasopharyngeal  adenoids.  The  lat- 
ter obstruct  the  posterior  nares  ;  compress  the  openings  of  the  Eusta- 
chian tubes ;  cause  mouth  breathing,  frequent  colds,  running  of  the 
nose,  lack  of  development  of  the  nose  and  the  body  of  the  maxillse ; 
aifect  the  voice ;  are  a  common  cause  of  deafness  and  otitis  media  and 
are  often  associated  with  mental  apathy  and  dullness.  After  puberty 
they  tend  to  diminish  and  the  nasopharynx  also  becomes  more  capa- 
cious ;  but  before  this  time  they  should  be  removed,  if  well  marked,  to 
avoid  the  evil  consequences. 

We  have  already  seen  the  position  of  the  openings  of  the  Eustachian 
tubes  (see  p.  58)  and  of  Rosenmiiller's  fossa  (recessus  infundibuliformis) 
just  behind  it.  The  latter  lies  beneath  the  tip  of  the  petrous  bone  and 
if  the  pharyngeal  tonsil  is  enlarged  this  fossa  may  be  reduced  to  a 
narrow  fissure.  The  pharyngeal  bursa  is  the  jiharyngeal  end  of  the 
diverticulum  that  forms  the  hypophysis  cerebri  and  is  present  in  infancy 
but  has  generally  disappeared  in  adult  life.  It  is  a  median  recess 
0])ening  below  tlie  pharyngeal  tonsil  and  reaching  upward  toward  the 
pharyngeal  tubercle. 

J,  The  roof  and  posterior  wall  of  the  nasopharynx  is  formed  by  the 
obliquely  sloped  under  surface  of  the  basilar  process  of  the  occipital 
bone  and  the  thick  layer  of  ligaments  and  fibrous  tissue  which  fills  in 


THE  NECK— ANTERIOR  MEDIAN  REGION.  117 

the  angle  between  the  occipital  bone  and  the  vertebne.  From  this 
fibrous  tissue,  or  the  periosteum,  spring  the  nasopharyngeal  polypi  which 
may  be  pedunculated  or  sessile,  benign  or  sarcomatous  and  which  occur 
most  often  in  male  children.  Even  when  benign  they  may  by  their 
growth  fill  up  the  nasopharynx,  depress  the  soft  palate,  become  pro- 
longed into  the  nasal  fossie,  the  maxillary  sinuses  and  even  through 
the  sphenopalatine  foramen  and  they  may  possibly  erode  the  base  of 
the  skull.  Their  reinoval  if  pedunculated  may  be  secured  Ijy  a  wire  snare 
orgalvano-cautery  loop  introduced  tiii'ough  the  nose,  through  a  tempo- 
rary resection  of  the  maxilla,  a  division  of  the  palate  and  in  many 
other  ways.  After  about  twenty  years  of  age  they  grow  much  less 
rapidly  or  not  at  all  and  are  even  said  to  atrophy,  hence  the  removal 
of  a  small  one  at  this  time  may  be  unnecessary  as  far  as  its  mechan- 
ical obstruction  is  concerned. 

The  lower  part  of  the  pharynx  is  funnel-shaped,  narrowing  to  its 
narrowest  point  at  its  lower  end.  All  below  the  nasopharynx  is  lined 
by  stratified  epithelium.  The  fan-shaped  conslridor  muscles  overlap 
one  another  from  below  upward.  Beneath  the  inferior  constrictor 
passes  the  inferior  laryngeal  nerve,  between  the  inferior  and  middle 
constrictors  the  superior  laryngeal  nerve  and  artery  pierce  the  thyro- 
hyoid membrane  to  reach  the  larynx  and  between  the  middle  and 
superior  constrictors  the  glossopharyngeal  nerve  and  the  stylo- 
pharyngeus  muscle  pass  downward  and  inward.  The  stylo-  and 
palatopharyngei  both  elevate  the  pharynx,  the  former  also  widens  it 
and  the  latter  narrows  very  strongly  the  isthmus  of  the  fauces  and 
helps  to  shut  off  the  mouth  from  the  pharynx  in  the  second  act  of 
deglutition. 

The  lymphatics  of  the  pharynx  pass  to  the  upper  deep  cervical 
nodes  whose  enlargement  may  depend  upon  an  inflammation  or  some 
other  affection  of  tlie  i)harynx.  The  lymphatics  of  the  upper  part  of 
the  pharynx  first  pass  through  the  postpharyngeal  node. 

THE  NECK. 

The  neck  or  the  passageway  between  the  head  and  the  thorax  is 
subject  to  wide  vari(dions  as  to  its  lengfJi,  size  and  shape.  The  abun- 
dance or  lack  of  adipose  tissue  is  largely  responsible  for  the  increase 
or  decrease  of  size  and  for  the  rounded  or  angular  shape.  In  extension 
of  the  neck  its  anterior  part  is  lengthened  and  in  flexion  is  shortened 
so  that  the  distance  of  its  movable  parts  from  the  sternum  or  the  lower 
jaw  varies  as  does  also  the  relation  of  these  jiarts  to  the  vertebra\ 
Hence  in  giving  the  relative  jiosition  of  its  landmarks  the  neck  is  sup- 
posed to  be  in  the  position  midway  between  flexion  and  extension,  /.<'., 
the  natural  upright  position,  unless  otherwise  stated. 

Landmarks  and  Surface  Markings. 

Anterior  Median  Region. —  In  the  receding  angle  of  the  chin  the 
hyoid  bone  and  its  great  eornua  can  be  made  out.    The  body  of  the  bone 


118  THE  HEAD  AIsD  NECK. 

is  on  a  level  with  the  fourth  cervical  vertebra  and  nearly  on  a  level  with 
the  angles  of  the  jaw.  The  upper  borders  of  the  cornua  are  guides  to 
the  lingual  arteries  which  run  just  above  them.  Below  the  hyoid  bone 
is  the  thyrohyoid  membrane  which  corresponds  posteriorly  with  the 
epiglottis  and  the  upper  aperture  of  the  larynx.  It  is  limited  inferiorly 
by  the  thyroid  cartilage  which  is  one  finger's  breadth  below  the  hyoid. 
The  parts  of  the  thyroid  cartilage  and  the  cricothyroid  space  between 
it  and  the  cricoid  cartilage  below  can  be  readily  made  out.  The  pro- 
jection of  the  thyroid  angle  is  much  more  prominent  in  males  after 
puberty,  but  the  cricoid  is  always  to  be  made  out.  It  correspoiids  to 
the  upper  end  of  the  sixth  cervical  vertebra,  to  the  junction  of  the 
pharynx  and  oesophagus  and  of  the  larynx  and  trachea  and  to  the 
crossing  of  the 'common  carotid  by  the  omohyoid  muscle.  Below  the 
cricoid  the  trachea  may  be  felt  but  its  individual  rings  can  not  be 
distino-uished.  As  it  descends  it  becomes  less  easily  felt,  for  ;it  is 
covered  more  deeply  by  the  lower  thicker  part  of  the  neck  so  that  at 
the  episternal  notch,  on  a  level  with  the  disc  between  the  second  and 
third  thoracic  vertebrae,  it  lies  nearly  1|  inch  from  the  surface. 

The  thyroid  gland  cannot  be  distinctly  felt  unless  enlarged.  On 
deep  pressure  opposite  the  cricoid  cartilage,  over  the  line  of  the  carotid 
artery,  the  prominent  anterior  tubercle  of  the  sixth  cervical  vertebra 
can  be  felt  and  the  artery  can  be  compressed  against  it,  as  advised  by 
Chassaignac.  Hence  it  is  called  the  carotid  tubercle  or  Chassaignac's 
tubercle.  As  the  omohyoid  crosses  the  carotid  at  this  point  the  latter 
is  more  superficial  and  more  easily  compressed  above  it. 

In  the  median  line  at  the  back  of  the  neck  there  is  a  slight  depression 
between  the  prominences  which  are  due  to  the  trapezius  and  complexus 
muscles  on  either  side.  At  the  upper  end  of  this  depression  is  the 
occipital  protuberance,  a  little  way  below  this  the  spine  of  the  axis  can 
be  felt  on  deep  pressure  and  below  this  the  spines  of  the  third,  fourth, 
fifth  and  sixth  vertebrae  can  be  felt  as  a  bony  ridge  but  not  as  indi- 
vidual spines.  The  spine  of  the  vertebra  prominens  (seventh  cervical) 
can  be  very  plainly  felt  and  represents  the  low^er  limit  of  the  neck. 
In  some  cases  the  sixth  spine  is  unusually  prominent  so  that  it  can  be 
distinctly  felt  and  may  l)e  mistaken  for  the  seventh  spine. 

At  the  side  of  the  neck  the  transverse  process  of  the  atlas  may  be 
felt  just  below  and  in  front  of  the  tip  of  the  mastoid  process  and  in  the 
upper  part  of  the  supraclavicular  fossa  the  transverse  process  of  the  sev- 
enth cer viced  vertebra  can  be  felt  on  deep  pressure.  The  angle  between 
the  submental  region  and  the  neck  corresponds  about  to  the  hyoid 
bone  and  is  continued  as  a  groove  and  a  crease  in  the  skin  backward 
and  upward  beneath  the  angle  of  the  jaw  to  the  subauricular  depres- 
sion in  front  of  the  mastoid,  behind  the  jaw  and  below  the  ear.  In 
very  fat  subjects  it  may  not  be  present.  The  groove  corresponds  to 
Kocher's  incision  for  the  upper  cervical  triangle. 

The  sternomastoid  muscle  is  altogether  the  most  important  land- 
mark of  the  neck.  It  is  prominent  in  thin  subjects  and  when  thrown 
into  action.      Its  anterior  border  is  the  thicker  and  better  marked  and 


THE  STh'RXOMASTOlI)   .MUSCLE.  119 

along  it  runs  a  communicating  branch  from  tlic  facial  to  tiic  anterior 
jugular  vein  in  the  lower  part  of  the  neck.  Extending  from  the  tip 
of  the  mastoid  to  a  point  just  internal  to  tiie  sternoclavicular  joint,  this 
border  overlies  the  coiniiion  (•(irotid  and  is  the  f/nide  for  iiki/iii/  iiici.slons. 
The  sheath  of  the  muscle  which  is  derived  from  the  superficial  layer 
of  the  deep  cervical  fascia  is  thicker  near  the  middle  of  the  muscle  than 
below  or  above.  Tiie  trianc/ular  interval  between  the  sternal  and  clavic- 
ular heads  o^  the  muscle  is  very  evident  in  thin  subjects.  Beneath  the 
lower  end  of  this  interval,  /.  c.,just  above  the  sternoclavicular  joint, 
lies  the  common  carotid  on  the  left  and  the  bifui'cation  of  the  in- 
nominate artery  on  the  right  side,  and  on  both  sides  the  margin  of  the 
pleura  and  lungs  at  a  deeper  level. 

The  action  of  the  sternomastoid  of  one  side  is  to  flex  the  head  for- 
ward and  to  the  side  of  the  muscle  and  rotate  it  to  the  opposite  side. 
The  fibers  from  the  sternal  fasciculus  cross  superficial  to  those  of  the 
clavicular  portion  so  as  to  be  inserted  behind  them  above.  The  cla- 
vicular portion  produces  the  lateral  flexion,  the  sternal  portion  the  rota- 
tion. This  difference  of  action  is  important  and  is  illustrated  in 
torticollis  or  wryneck,  a  condition  often  congenital,  sometimes  acquired 
and  due  to  a  contracture  or  spasmodic  contraction  of  one  muscle  or  the 
paralysis  of  the  opposite  one. 

The  congenital  cases  are  due  most  often  to  an  injury  at  birth,  too 
great  traction  on  the  after-coming  head  or  the  pressure  of  the  forceps. 
A  haematoma  forms  within  the  sheath  of  the  ruptured  or  injured 
muscle  and  the  injured  part  is  replaced  by  fibrous  tissue,  or  the 
pressure  of  the  extravasation  causes  an  ischa?mic  degeneration  and 
contracture.  According  to  some  the  latter  may  occur  from  pressure  in 
utero.  The  deformity  may  not  be  noticed  for  some  time  after  birth 
and  increases  with  the  cicatricial  contraction  of  the  injured  muscle  and 
cervical  fascia  and  with  the  diminished  growth  of  the  muscle.  In 
this  form  of  wryneck  the  treatment  is  division  of  the  tnusclc.  This 
was  formerly  practiced  subcutaneoaslf/  2  cm.  above  its  lower  end  in 
adults,  1  cm.  above  in  children,  so  as  to  avoid  the  anterior  jugular 
vein  which  passes  beneath  the  lower  end  of  the  muscle  to  join  the 
external  jugular,  which  lies  along  its  posterior  border.  The  latter 
vein  is  generally  out  of  danger  as  only  the  sternal  portion  of  the  mus- 
cle is  usually  divided,  for  it  is  the  rotation  due  to  this  portion  which 
is  particularly  characteristic  of  torticollis.  The  great  vessels  are 
not  in  danger  as  they  are  here  overlapped  by  the  sternohyoid  and 
sternothyroid  muscles.  The  open  division  is  far  preferable  as  every- 
thing can  be  divided  that  prevents  the  correction  of  the  deformity 
including  the  contracted  sheath  and  the  cervical  fascia.  It  should  l)e 
done  before  secondary  changes  in  the  vertebrie  and  soft  parts  have 
taken  place.  Spastic  wryneck  may  be  due  to  a  reflex  irritation.  The 
spinal  acccssort/  nerve  together  with  filaments  from  the  anterior  divisions 
of  the  second  and  third  cervical  nerves  supplies  the  muscle.  In  such 
forms  of  wryneck  the  spi)ial  accessor}/  is  often  excised  and  may  be 
exposed  where   it  reaches  the  anterior  border  of  the  muscle,  1  to   H 


120  THE  HEAD  AND  NECK. 

inch  below  the  tip  of  the  mastoid.  This  nerve  traverses  the  mnscle 
about  the  junction  of  its  upper  and  middle  thirds,  emerges  at  the 
posterior  border  a  little  above  its  middle,  crosses  the  posterior  triangle 
and  passes  under  the  trapezius  on  a  level  with  the  seventh  cervical 
spine.  It  supplies  the  latter  in  conjunction  with  the  third  and  fourth 
cervical  nerves.  In  some  severe  cases  of  spastic  wryneck  the  trape- 
zius and  other  muscles  at  the  back  of  the  neck  are  involved  and  be- 
sides the  spinal  accessory  the  upper  four  cervical  nerves  may  require 
resection. 

Besides  forming  a  guide  for  the  incision  in  many  operations  the 
sternomastoid  divides  the  antero-Iateral  region  of  the  neck,  in  front  of 
the  trapezius  muscle,  into  two  triangles.  These  primary  surgical  triangles 
are  sahdivided  into  several  smaller  surgiccd  triangles  by  muscles  which 
are  also_  of  service  as  landmarks  in  operations  on  the  neck.  These 
triangles  bounded  by  and  containing  landmarks  are  of  practical  use, 
for  their  contents  can  be  located  with  reference  to  these  boundaries  and 
landmarks. 

The  posterior  triangle  (Fig.  29)  is  subdivided  by  the  posterior  belly 
of  the  omohi/oid  into  an  inferior  or  subclavian  and  a  superior  or  oc- 
cipital triangle.  The  occipital  triangle  bounded  by  the  sternomastoid 
in  front,  the  trapezius  behind  and  the  omohyoid  below  contains  com- 
paratively little  of  practical  importance.  The  superjicicd  cervical  nerves 
appear  at  the  posterior  border  of  the  sternomastoid.  The  small  occip- 
ital, great  auricular  and  transverse  cervical  nerves  emerge  just  above 
the  center  of  the  muscle,  the  first  running  up  to  the  scalp  near  the 
posterior  border  of  the  muscle,  the  second  across  the  muscle  to  the 
back  of  the  ear,  the  third  straight  forwards  across  the  muscle.  Lines 
drawn  from  the  middle  of  the  posterior  border  of  the  muscle  to  the 
sternum,  the  middle  of  the  clavicle  and  the  acromion  represent  the 
course  of  the  suprasternal,  supraclavicular  and  supraacromial  nerves. 
The  xpinaJ  areessori/  crosses  this  triangle  as  described  above. 

The  subclavian  triangle  (Fig.  29)  corresponds  about  to  the  wide 
depression  above  the  clavicle,  the  supraclavicular  fossa,  which  is  well 
marked  except  in  stout  subjects  and  infants.  In  some  fractures  of  the 
clavicle  this  fossa  may  be  obliterated  or  even  replaced  by  a  prominence. 
This  triangle  is  bounded  below  by  the  clavicle,  above  by  the  posterior 
belly  of  the  omohyoid  and  in  front  by  the  posterior  border  of  the 
sternomastoid.  The  posterior  belly  of  the  omohyoid  can  be  made  out 
in  thin  necks  and  especially  when  in  action.  It  runs  along  a  little 
above  the  clavicle,  inclining  somewhat  upwards  as  it  passes  forwards 
to  pass  beneath  the  sternomastoid.  The  posterior  border  of  the  latter 
can  be  made  out  when  in  action.  The  attachment  of  its  clavicxdar 
portion  varies  in  width  and  in  some  cases,  especially  in  muscular  sub- 
jects, it  encroaches  on  the  subclavian  triangle  so  as  to  require  division 
in  operations  in  this  region. 

At  a  deeper  level  the  posterior  border  of  the  scalenus  anterior  mus- 
cle roughly  corresponds  to  that  of  the  sternomastoid  though  it  has  a 
somewhat  different  direction.     Hence  we  may  say  that  there  are  two 


PLATE   VI  1  1 


FIG.  29. 


SPINAL    ACCES- 
SORY   NERVE 


SERRATUS  ym 
MAGNUS — i™^' 
MUSCLE 


POSTERIOR    SCAP. 
ARTERY 


SCALENUS 
MEDIUS 
MUSCLE 

PH  RENIC 
NERVE 


BRACHIAL 
PLEXUS 


SUPRASCAP. 
ARTERY 


LONG   THORA- 
CIC   NERVE 


The  occipital  and  subclavian  triangles.  The  head  is 
turned  away  to  the  left  and  the  clavicle  is  strongly  de- 
pressed. (The  posterior  scapular  artery  is  unusually  deep 
and  has  separated  unusually  early  from  the  superficial 
cervical  artery.)     (Zuckerkandl.  ) 


THE  SUBCLAVIAN  ARTERY.  121 

triano;]es  of  which  the  deeper  is  bounded  in  front  by  the  scalenus  ante- 
rior. The  phrenic  nerve  lies  in  front  of  this  muscle  and  crosses  it  ob- 
liquely, being  directed  toward  the  lower  end  of  its  inner  border,  where 
it  passes  behind  the  subclavian  vein.  This  nerve  co//i/)U'nc^.s- about  the 
level  of  the  hyoid  bone  and  \sJon/ial  hi/  brandies  from  the  third  and 
fourth  cervical.  It  lies  deeply  and  descends  underneath  the  sterno- 
mastoid,  being  about  midway  between  its  two  borders  at  the  level  of 
the  cricoid  cartilage. 

Crossing  the  subclavian  triangle  in  a  line  from  the  angle  of  the  jaw 
to  the  center  of  the  clavicle  is  the  external  jugular  vein.  It  crosses 
the  sternomastoid  obliquely  to  reach  its  posterior  border,  the  lower 
third  of  which  it  follows.  The  lower  dilated  end  or  ''  sinua"  of  the 
vein,  between  a  point  1?,  inches  above  the  clavicle,  where  it  pierces  and 
is  adherent  to  the  deep  cervical  fascia,  and  its  entrance  into  the  sub- 
clavian vein  in  front  of  the  scalenus  anterior,  receives  the  transverse 
cervical  and  suprascapular  veins.  These  veins  sometimes  present  a 
plexiform  arrangement  in  the  subclavian  triangle  and  may  render 
more  difficult  the  operations  in  this  triangle.  Owing  to  its  adherence 
to  the  deep  cervical  fascia  the  "  sinus  "  of  this  vein  remains  patent  and 
is  liable  to  admit  air  when  it  is  opened. 

At  the  base  of  the  triangle  the  suhclavian  artery  describes  a  curve 
from  the  sternoclavicular  joint  to  the  center  of  the  clavicle,  the  highest 
point  of  the  curve  rising  }j  to  \  inch  above  that  bone.  On  the  left 
side  the  artery  lies  more  deeply  and  does  not  rise  so  high  in  the  neck 
as  on  the  right  side.  At  the  outer  border  of  the  sternomastoid  and 
just  above  the  clavicle  the  pidmtion  of  the  artery  may  be  felt  and  it 
may  be  compressed  against  the  first  rib  by  pressure  downward  and 
backward,  when  the  arm  is  drawn  downward.  Normally  the  artery 
does  not  rest  directly  upon  the  rib  but  is  slung,  as  it  were,  one  fourth 
inch  or  more  above  it  between  the  scaleni  anterior  and  medius. 

The  artery  may  be  ligated  in  its  third  portion  ;  wh.ich  lies  in  this 
triangle  external  to  the  scalenus  anterior,  Ijy  an  incision  about  four 
inches  long  a  finger's  breadth  above  the  clavicle.  The  layers  divided  in 
reaching  the  artery  are  the  following  :  (1)  Skin  ;  (2)  scanty  subcutane- 
ous connective  tissue  ;  (3)  platysma  ;  (4)  second  connective  tissue  layer 
with  fat;  (5)  superficial  layer  of  deep  cervical  fascia,  from  the  sheaths 
of  the  sternomastoid  and  trapezius ;  (G)  third  layer  of  loose  connec- 
tive tissue  ;  (7)  middle  layer  of  deep  cervical  fascia,  forming  the  sheath 
of  omohyoid  and  connected  with  the  sul^clavian  vein  ;  (8)  fourth 
layer  of  connective  tissue  in  which  lie  the  lymph  nodes,  the  end 
of  the  external  jugular  vein,  the  subclavian  artery  and  vein  and  their 
branches,  and  the  brachial  plexus,  etc.  The  e.rfcrnal  jxirjxdar  vein  (see 
above)  should  be  nd  between  two  ligatures  as  should  also  the  supra- 
scapular vein.  The  siiprascaindai-  and  transverse  cervical  hranc/te.^  of 
the  subclavian  artery  run  outward  parallel  with  the  clavicle,  the  f»)r- 
mer  behind,  the  latter  just  above  it  where  its  pulsation  may  usually 
be  felt.  The  suprdclavicidar  nerves  descend  in  front  of  this  triangle. 
The  subclavian  vein  lies  at  a  lower  level,  below,  internal  to  and  in  front 


122  THE   HEAD  AND  NECK. 

of  the  artery  and  under  cover  of  the  clavicle.  To  avoid  injury  to  the 
vein  the  aneurism  needle  should  he  passed  from  below  and  in  front. 

At  the  inner  end  of  this  triangle  the  siibdavkin  vein  is  separated 
from  the  artery  by  the  scalenus  anterior.  Behind  the  latter  the  artery 
lies  in  contact  with  and  grooves  the  dome  of  the  pleura  and  the  apex 
of  the  lung.  These  structures  should  be  carefully  avoided  in  passing 
the  ligature.  Strict  asepsis  should  be  observed  to  avoid  inflammation 
of  the  pleura  and  empyema.  The  pjleura  has  also  been  opened  in 
removing  deeply  seated  tumors  of  the  base  of  the  neck  and,  together 
with  the  lung,  has  been  wounded  in  stab  Avounds  of  the  neck  and  by 
bony  fragments  in  severe  fractures  of  the  clavicle  or  first  rib.  Abscess 
in  this  part  of  the  neck  has  opened  into  the  pleura  and  pleurisy  lias 
also  followed  cellulitis  of  this  part.  Hernia  of  the  lung  into  the 
neck  during  violent  paroxysms  of  coughing  has  been  reported.  For 
the  position  of  tlie  lung  and  pleura  in  the  root  of  the  neck  see  p.  215. 

The  brachial  plexus  can  be /eft  and,  in  very  thin  subjects,  even  seen 
in  the  subclavian  triangle.  Its  upper  limit  is  shown  by  a  line  from  the 
side  of  the  cricoid  cartilage  to  a  point  a  little  external  to  the  middle  of 
the  clavicle.  It  lies  just  above  the  subclavian  artery,  its  lowest  cord 
being  partly  behind  the  artery,  and  it  emerges  like  the  artery  from 
between  the  anterior  and  middle  scalene  muscles.  Hence  it  is  exposed 
and  may  serve  as  a  guide  in  ligating  the  subclavian  artery.  It  has 
occasionally  happened  that  a  cord  of  this  plexus  has  been  included  in 
the  ligature  in  place  of  the  artery  but  the  mistake  is  evident  from  the 
continued  pulsation  in  the  arteries  of  the  arm. 

The  third  portion  of  the  artery  is  the  seat  of  election  for  ligature  for 
it  is  more  superficial  and  has  no  branches  and  fewer  vital  relations. 
The  second  part  lies  deeply  behind  the  scalenus  anterior  on  which  lies 
the  phrenic  nerve.  It  includes  the  highest  point  of  its  curve,  gives  off 
one  branch  (superior  intercostal)  and  is  in  close  relation  with  the  pleura. 
The  first  portion  is  crossed  in  front  by  the  internal  jugular,  vertebral 
and  the  commencement  of  the  innominate  veins,  and  on  the  right  side 
by  the  pneumogastric  and  a  loop  of  the  sympathetic  nerve.  On  the  left 
side  the  thoracic  duct  arches  over  it.  The  subclavian  vein  is  below 
and  in  front  of  it  and  gives  off  three  large  branches.  Below  and 
behind  it  are  the  pleura  and  lung  and,  on  the  right  side,  the  recurrent 
laryngeal  nerve.  Hence  and  because  of  its  deep  situation  it  is  not 
well  suited  for  the  application  of  a  ligature. 

After  ligature  of  the  second  and  third  portions  of  the  subclavian  the 
collateral  circulation  is  established  and  carried  on  principally  through 
the  anastomoses,  (1)  of  the  suprascapular  and  posterior  scapular  with 
the  acromiothoracic,  infra-  and  subscapular  and  dorsalis  scapulae  ;  (2) 
of  the  superior  intercostal,  aortic  intercostal  and  internal  mammary 
with  the  long  thoracic  and  the  scapular  arteries  ;  (o)  of  small  branches 
in  the  axilla. 

Cervical  ribs  occur  usually  on  both  sides,  sometimes  on  one  side  only. 
As  a  rule  they  are  articulated  with  the  seventh  cervical  vertebrce  and  its 
transverse  process  but  sometimes  they  are  fused  with  it.     They  may 


THE  SUBMAXILLARY   TRIANGLE.  123 

be  very  short,  when  they  are  often  mistaken  for  exostoses,  or  they  may 
extend  well  forward  and  be  connected  by  bony,  cartilaginous  or  fibrous 
union  with  the  first  rib,  its  cartilaije  or  the  sternum.  In  such  cases 
the  suhc/(iri(in  (/rfrr//  and  hraoJual  jtle.vus  pass  over  them  and  the  anterior, 
and  sometimes  the  middle,  scalene  nuiscle  is  attached  to  them.  The 
distinct  pnlmtion  of  the  artery  at  a  high  level  in  such  cases  may  lead 
to  a  diagnosis  of  anearism  and  in  fact  the  latter  condition  seems  to  be 
not  uncommonly  associated  M'ith  cervical  ribs.  The  rib  may  form  a 
distinct  projection  in  thin  persons  but  as  a  rule  it  causes  no  si/nijjfom.s. 
Sometimes  however  the  circulation  in  the  arm  and  the  function  of  the 
branches  of  the  brachial  plexus  is  interfered  with,  apparently  as  the 
result  of  pressure  by  the  ribs  or  of  the  sharp  bend  in  the  artery,  and 
hence  i-enKiral  of  the  ril)  is  indicated. 

The  anterior  cervical  triangle,  in  front  of  the  sternomastoid,  is 
subdivided  by  the  digastric  muscle  above  and  the  anterior  belly  of  the 
omohyoid  below  into  three  smaller  triangles. 

The  submaxillary  triangle,  or  the  upper  one  of  these  three,  is 
bounded  above  by  the  lower  border  of  the  jaw  and  the  line  of  this  con- 
tinued back  to  the  mastoid  process,  below  by  the  posterior  belly  of  the 
digastric  muscle  and  the  hyoid  bone,  in  front  by  the  median  line.  It 
corresponds  to  the  s;  prahyoid  rer/ion  of  some  authors.  That  part  of 
its  posterior  angle  behind  the  thick  fascial  band  from  the  sheath  of 
the  sternomastoid  to  the  angle  of  the  jaw,  belongs  to  and  has  been 
described  under  the  parotid  region.  The  posterior  belly  of  the  digastric 
muscle  coincides  with  a  line  from  the  mastoid  process  to  a  point  just 
above  the  junction  of  the  great  cornu  and  body  of  the  hyoid  bone. 

In  the  normal  position  of  the  head  this  region  lies  in  a  nearly  hori- 
zontal plane  which  accounts  for  the  rarity  of  wounds  here.  When  the 
head  is  extended,  as  it  is  in  operations  on  this  region,  the  latter  is 
oblique  from  above  downward  and  inward.  In  incisions  into  it  we  meet 
the  following  layers  in  succession,  (1)  skin;  (2)  platysma,  with  a  con- 
nective tissue  layer  on  either  side  ;  (3)  the  superficial  layer  of  the  deep 
cervical  fascia  forming  a  sheath  for  (4)  the  submaxillary  gland  ;  (5) 
the  muscular  floor  of  the  triangle  with  vessels  and  nerves  covered  by 
a  deeper  layer  of  fascia  which  is  attached  to  the  hyoid  bone  and  the 
mylohyoid  ridge  and  forms  a  sheath  for  the  digastric  muscle. 

The  platysma  is  quite  closely  co)inected  with  the  skin,  so  that  the  ed(/e^ 
of  wounds  crossing  the  course  of  the  muscle  are  likely  to  be  turned  in. 
Owing  to  the  loose  tissue  beneath  the  muscle  the  skin  and  ]>latysma 
may  l)e  readily  used  as  a  //a/>  and  the  tlaj)  so  formed  can  be  freely  dis- 
placed to  cover  defects  in  the  lower  lip  and  lower  part  of  the  face. 
But  to  cover  defects  in  the  lips  or  cheek  such  flaps  possess  the  disad- 
vantage of  not  beinir  lined  bv  mucosa  so  that  the  final  results  are  dis- 
appointing,  owing  to  the  adhesions  and  contraction  of  the  flap  (see  p. 
99).  The  amount  of  Jut  between  the  skin  and  deep  fascia  is  very 
variable.  There  is  often  a  diffuse  deposit  of  fat,  especially  in  the  area 
between  the  chin  and  the  hyoid  bone,  |)roducing  the  so-called  double  or 
triple  ehin,  thus  converting  the  normal  concavity  of  this  region  into  a 
convexity. 


124  THE  HEAD  AND  NECK. 

The  superficial  layer  of  the  deep  fascia  splits  to  enclose  the  suh- 
maxillary  gland  in  a  fibrous  .sheath  and  is  adherent  to  the  lower  border 
of  the  jaw  and  to  the  hyoid  bone.  It  is  continuom  laterally  with  the 
sheath  of  the  sternomastoid  and  of  the  parotid  gland  and  in  the  median 
line  with  the  similar  layer  of  the  opposite  side.  It  is  connected  with 
the  thick  fascial  band  from  the  sternomastoid  to  the  angle  of  the  jaw, 
which  separates  the  submaxillary  from  the  parotid  sheath. 

The  submaxillary  gland  differs  from  the  parotid  in  that  its  fibrous 
septa  are  not  closely  connected  with  the  inside  of  its  sheath,  but  it  is 
separated  from  its  sheath  by  loose  connective  tissue  so  that  it  can  be 
readily  enucleated.  The  submaxillary  gland  is  seldom  inflamed  pri- 
marily, though  of  all  salivary  glands  it  is  most  frequently  the  seat  of 
calculi,  which  by  obstructing  the  duct  may  produce  sudden,  recurring 
attacks  of  acute,  painful  sicelling  of  the  gland,  sometimes  accompanied 
by  suppuration. 

The  contents  of  the  submaxillary  gland  sheath  of  the  most  practical 
importance  are  the  lymph  nodes  on  the  surface  of  the  gland  which 
receive  lymphatics  from  the  lips,  the  fore  part  of  the  tongue,  the  floor 
of  the  mouth,  the  nose,  the  forehead,  the  nasal  half  of  both  eyelids 
and  the  submaxillary  and  sublingual  glands.  Hence  these  nodes  may 
be  affected  in  any  inflammatory  affection  or  malignant  new-growth  of 
these  parts,  and  the  enlarged  or  broken-down  nodes  require  opening 
or  removal  according  to  circumstances.  When  these  lymph  nodes  are 
removed  it  is  often  impossible  to  spare  the  gland,  especially  in  can- 
cerous conditions,  and  the  entire  contents  of  the  digastric  triangle  are 
then  removed  together.  In  this  procedure  the  most  important  rela- 
tion of  tiie  gland  is  with  the  facial  artery  which  grooves  its  postero- 
superior  part  passing  from  its  deep  surface  to  the  border  of  the  jaw 
just  in  front  of  the  masseter.  The  general  direction  of  the  tortuous 
facial  artery  is  between  the  latter  point  and  its  origin  just  above  and 
outside  the  tip  of  the  great  cornu  of  the  hyoid  bone,  passing  be- 
neath the  posterior  belly  of  the  digastric  in  its  course.  The  facial  vein, 
usually  separated  from  the  artery  by  the  submaxillary  gland,  the  pos- 
terior belly  of  the  digastric,  the  stylohyoid  muscle  and  the  hypoglos- 
sal nerve,  crosses  superficial  to  the  artery  to  become  more  posterior  at 
the  border  of  the  jaw.  The  submental  branch,  given  off  from  the 
artery  beneath  the  gland,  runs  forward  on  its  deep  surface.     (Fig.  30.) 

When  enlarged  the  posterior  extremity  of  the  gland,  grooved  by  the 
facial  artery  on  its  deep  and  superior  aspect,  may  overlap  the  external 
carotid  from  which  it  is  separated  by  the  posterior  belly  of  the  digas- 
tric, the  stylohyoid  and  the  band  from  the  sternomastoid  to  the  angle 
of  the  jaw.  The  gland  lies  partly  hidden  beneath  the  mandible.  Its 
accessory  portion  and  duct  (Wharton's)  (see  page  lOG),  pass  forward  in 
the  floor  of  the  ujouth  on  the  deep  surface  of  the  mylohyoid.  Notice 
the  close  relation  between  this  region  and  the  floor  of  the  mouth  ;  in- 
flammatory affections  may  spread  from  one  to  the  other  behind  the 
mylohyoid.  In  this  connection  it  should  be  remembered  that  the 
commonest  cause  of  abscess  in  the  submaxillary  region  is  dented  caries 


PLATE    IX 


FTG    30. 


The  salivary  glands.  The  right  half  of  the  body  of 
the  mandible  has  been  removed.  GL.W.,  gland  of  Weber. 
GL.  B.,  gland  of  Blandin.     (Gerrish,  after  Testut.) 


POSTERIO 

BELLY    OF 

DIGASTRIC 

MUSCLE 


HYPOGLOSS 
NERVE 


GREAT    CORNU 
OF   HYOID 


LINGUAL    Tfi, ANGLE, 
WITH    COURSE    OF 
LING.    ARTERY 
COVERED   BY    HYO- 
GLOSSUS 


Submaxillary  triangle  and  the  deep  relations  of  the 
submaxillary  gland.  Dotted  white  line  indicates  the  posi- 
tion of  the  gland,  dotted  red  line  the  course  of  the  lingual 
artery  beneath  the  hyoglossus.     (Testut. ) 


FIG 


EXT.  CAROT 
ARTERY 


GLOSSO- 

PHARYNG. 

POST.  AURIC    NERVE 

ARTERY 


OCCIPITAL    ARTERY 

SPINAL    ACCES- 
SORY   NERVE 
HYPOGLOSSAL    NERVE 
INTERNAL  CAROT. 
ARTERY 
DESCENDENS   NONI   N. 
LINGUAL    VEIN 

COMMON     FACIAL 
VEIN 


INGUAL  ARTERY 
UP  LARYNGEAL 
NERVE,  INTER- 
NAL   BRANCH. 


UP  LARYNGEAL 
NERVE  EXTER- 
NAL   BRANCH 


Structures  of  the  upper  part  of  neck  in  the  superior 
carotid  and  submaxillary  triangles.  The  sternomastoid 
muscle  is  retracted  somewhat  backward,  the  digastric  is 
divided  and   the  omohyoid  removed.     (Zuckerkandl.) 


IHE  LINGUAL    VESSELS  AND   TRIANGLE.  125 

followed  by  alveolar  |)eriostitis  of  the  mandible  (see  pages  100-1  j.  In- 
flammation of  the  submaxillary  gland  and  of  the  lymph  nodes  within 
its  sheath,  or  the  abscess  resulting  therefrom,  is  more  circumscribed 
than  the  last-mentioned  abscesses  and  in  opening  submaxillary  ab- 
scesses it  should  be  remembered  that  the  facial  vessels  and  their 
branches  are  beneath  the  sheath  and  not  exposed  to  injury. 

The  two  bellies  of  the  digastric  below  and  the  jaw  above  frame  a 
deep  irianf/Ie  lodging  the  submaxillary  gland.  The  Jioor  of  this  tri- 
angle is  formed  by  the  mylohyoid  and  hyoglossus  muscles  from  be- 
fore backward.  Passing  forward  on  the  latter  muscle  i.-,  the  Injpo- 
glossal  nerve  accompanied  by  the  ranine  vein.  The  lingual  artery  has 
much  the  same  course,  at  a  somewhat  lower  level,  but  it  lies  beneath 
the  hyoglossus  and  upon  the  genioglossus  muscle.  This  artery,  arising 
opposite  the  tip  of  the  great  cornu  of  the  hyoid,  runs  forward  just  above 
that  process  and  is  usually  ligated  in  the  "lingual  triangle."  This 
triangle  is  bounded  above  by  the  hypoglossal  nerve,  in  front  by  the 
posterior  border  of  the  mylohyoid  and  behind  and  below  by  the  pos- 
terior belly  of  the  digastric.  (Fig.  31.)  It  is  readily  exposed  on 
turning  up  the  submaxillary  gland.  The  lingual  artery  is  here  readied 
by  separating  the  more  or  less  vertical  fibers  of  the  rather  thin  hyo- 
glossus muscle,  at  right  angles  to  which  it  runs.  It  is  accompanied 
by  one  or  several  venre  comites. 

To  include  the  dorsalis  Ihir/me  branch  it  has  been  advised  by  Fara- 
boeuf  and  others  to  ligate  the  first  jjortion  of  the  artery,  behind  the 
hyoglossus  muscle  near  whose  posterior  border  this  branch  is  given 
off  and  passes  upward.  For  this  purpose  the  end  of  the  great  cornu 
of  the  hyoid  bone  is  our  guide,  to  which  the  posterior  fibers  of  this 
muscle  are  attached.  This  part  of  the  artery  is  crossed  by  the  hypo- 
glossal nerve,  the  facial  and  lingual  veins  and  the  digastric  and  stylo- 
hyoid muscles. 

The  sublingual  artery,  usually  given  off  at  the  anterior  border  of 
the  hyoglossus,  may  sometimes  arise  in  the  lingual  triangle  and  might 
then  be  ligated  in  place  of  the  trunk,  so  that  the  circulation  on  the 
same  side  of  the  tongue  would  not  be  controlled  by  the  ligature.  This 
is  probably  not  the  common  cause  of  hemorrhage  in  operations  on  the 
tongue  after  ligation  of  the  lingual  but  rather  an  anomali/  wherein  the 
lingual  on  one  side  is  small  and  its  place  is  taken  by  a  large  branch 
from  the  opposite  lingual. 

Underneath  the  deep  fascia  in  the  median  line  beneath  the  chin  and 
lying  on  the  mylohyoid  muscle  are  two  or  three  /i/inii/i  nodes  which 
receive  vessels  from  the  middle  of  the  lower  lip  and  the  chin  and  may 
be  enlarged  in  affections  of  these  parts. 

The  submaxillary  gland  and  its  surrounding  lymph  nodes  are  com- 
paratively superfieiak  and  may  be  easily /•mc/(f(/  for  removal  or  for 
elevation  to  expose  the  lingual  triangle,  by  a  cn.rred  incisin)!  from  just 
below  the  angle  of  the  jaw  to  the  body  of  the  hyoid  bone  and  up 
toward  the  symphysis.  Kocher's  so-called  "normal  incision"  for  the 
upper  lateral  cervical  triangle  passes  from  in  front  of  the  tip  of  the 


126  THE  HEAD   AND  NECK. 

mastoid  to  the  middle  of  the  hyoid  bone  and  lies  just  below  the  digas- 
tric and  the  other  suprahyoid  muscles.  It  avoids  important  nerves, 
for  those  crossing  it  can  be  retracted  posteriorly,  and  it  crosses  the 
point  where  the  branching  of  the  great  vessels  occurs. 

The  subhyoid  region  is  divided  into  the  two  carotid  triangles  by  the 
anterior  belly  of  the  omohyoid  muscle.  The  latter  follows  a  line  from 
the  side  of  the  body  of  the  hyoid  at  its  lower  border  to  the  anterior 
border  of  the  sternomastoid  at  the  level  of  the  cricoid  cartilage,  where 
it  crosses  in  front  of  the  common  carotid  and  behind  the  sterno- 
mastoid. 

The  superior  carotid  triangle  is  bounded  behind  by  the  sterno- 
mastoid, above  by  the  posterior  belly  of  the  digastric  and  below  and  in 
front  by  the  anterior  belly  of  the  omohyoid.  Its  floor  is  formed  by 
the  thyrohyoid,  hyoglossus  and  inferior  and  middle  constrictors  of  the 
pharynx.  It  contains,  beneath  the  skin  the  platysraa  and  the  superficial 
and  middle  layers  of  the  deep  cervical  fascia,  the  lower  portion  of  the 
external  carotid  with  the  commencement  of  its  lower  five  branches 
and,  beneath  the  anterior  margin  of  the  sternomastoid,  the  upper  end 
of  the  common  carotid  and  the  lower  part  of  the  internal  carotid. 

The  superior  thyroid  artery  arises  a  little  below  the  great  cornu  of  the 
hyoid  and  runs  downward  and  forward  to  the  back  part  of  the  thyroid 
cartilage  and  the  upper  and  outer  part  of  the  thyroid  body.  It  is 
superficial  only  at  its  commencement.  Beneath  it  is  the  superior  laryn- 
geal nerve  whose  internal  branch,  with  the  superior  laryngeal  branch 
of  this  artery,  pierces  the  thyrohyoid  membrane.  Its  sternomastoid 
branch,  arising  about  half  an  inch  from  its  origin,  crosses  the  upper 
end  of  the  common  carotid  to  reach  the  sternomastoid  muscle. 

The  occipital  artery,  arising  at  the  same  level  as  the  facial  (p.  124),  but 
from  the  posterior  aspect  of  the  artery,  passes  upward  and  backward 
to  the  interval  between  the  mastoid  process  and  the  transverse  process 
of  the  atlas.  It  finally  enters  the  scalp  with  the  great  occipital  nerve 
midway  between  the  mastoid  process  and  the  external  occipital  protu- 
berance and  follows  thence  the  line  of  the  lambdoid  suture.  The  facial 
and  lingual  branches  have  already  been  referred  to. 

The  inferior  carotid  triangle  is  bounded  above  by  the  anterior 
belly  of  the  omohyoid,  behind  by  the  sternomastoid  and  in  front  or 
mesially  by  the  median  line.  The  carotid  triangles  are  so  called  from 
their  containing  the  carotid  vessels  which  strictly  speaking  are  in  great 
part  behind  these  triangles  under  cover  of  the  anterior  border  of  the 
sternomastoid. 

The  Great  Vessels. — The  line  of  the  carotid  is  from  the  sterno- 
clavicular joint  to  a  point  midway  between  the  angle  of  the  jaw  and  the 
mastoid  process.  The  common  carotid  extends  up  to  the  upper  border 
of  the  thyroid  cartilage,  on  a  level  with  the  third  cervical  vertebra, 
where  it  bifurcates  into  the  external  and  internal  carotids.  At  its 
point  of  bifurcation  it  presents  a  slight  dilatation  which  is  the  most  com- 
mon situation  for  aneurisms,  for  there  appears  to  be  some  resistance  to 
the  blood  current  here.     Such  an  aneurism  may  demand  the  proximal 


THE  COMMOX  CAROTID   ARTERY.  127 

iujature  of  the  carotid.  The  carotid,  having  no  collateral  Ijranches,  is 
also  the  vessel  in  which  the  didal  ligature  (Basador's  method)  is  best 
adapted.  It  is  most  often  ])racticcd  for  aneurisms  in  its  lower  part, 
where  they  are  not  uncommon.  As  there  are  no  collateral  ijranches 
between  the  aneurism  and  the  ligature  the  latter,  by  occluding  the 
artery,  prevents  the  blood  ])assing  through  the  aneurism.  Wardrop's 
operation,  or  the  distal  ligature  of  large  branches  for  aneurism  of  a 
main  trunk,  has  been  tried  here  and  is  now  limited  to  the  ligature  of 
the  carotid  and  the  third  portion  of  the  subclavian  for  aneurisms  of 
the  innominate  or,  occasionally,  of  the  aorta.  But  as  there  are  large 
branches  given  off  from  the  first  and  second  portions  of  the  subclavian, 
which  under  the  conditions  present  can  scarcely  l)e  ligated,  the  success 
of  this  method  is  not  so  great  as  it  might  otherwise  be. 

The  common  carotid  is  now  ligated  mainly  for  aneurism  or  wound  of 
the  artery  itself  The  external  or  internal  carotid,  instead  of  the  com- 
mon carotid,  is  now  lir/ated  to  check  hemorrhage  from  their  branches 
due  to  wounds,  to  prevent  hemorrhage  in  the  removal  of  neoplasms 
and  to  check  the  growth  of  the  latter.  One  objection  to  ligature  of 
the  common  carotid  is  the  occasional  effect  on  the  brain,  but  as  a  rule  the 
two  vertebrals  and  the  opposite  carotid  with  their  free  anastomosis  in 
the  circle  of  Willis  are  sufficient  to  obviate  this.  The  rouiuion  carotid 
may  be  secured  at  any  part  in  the  neck  but  the  place  of  election  is  just 
above  the  omohyoid,  where  it  is  superficial,  being  covered  only  by  the 
skin,  platysma  and  superficial  and  middle  layers  of  the  deep  cervical 
fascia. 

The  incision  is  carried  along:  the  anterior  border  of  the  sterno- 
mastoid  with  the  center  opposite  the  cricoid  cartilage.  A  communi- 
cating vein  between  the  facial  and  the  anterior  jugular  veins  may  be 
met  with  in  the  line  of  incision.  After  incising  the  superficial  layer 
of  the  cervical  fascia  along  the  anterior  border  of  the  sternomastoid 
we  meet  the  omohyoid  crossing  obliquely  the  line  of  incision  at  the 
level  of  the  cricoid  cartilage.  Then,  incising  the  middle  layer  of  the 
cervical  fascia  above  the  omohyoid  in  the  same  line,  we  expose  the 
carotid  sheath  which  is  here  crossed  by  the  sternomastoid  arteri/  and 
sometimes  by  the  superior  thyroid  veins.  The  middle  thyroid  veins 
may  also  cross  it  here  but  usually  with  the  omohyoid  muscle.  A 
valuable  guide  to  the  artery,  about  the  crossing  point  of  the  omo- 
hyoid and  about  2}  inches  above  the  clavicle,  is  the  carotid  tidjrrc/c 
or  anterior  tubercle  of  the  sixth  cervical  vertebra,  directly  over  which 
lies  the  artery  and  against  which  it  may  be  compressed. 

This  tubercle  serves  also  as  a  guide  to  the  vertebral  artery  which 
lies  on  the  transverse  process  of  the  seventh  cervical  vertebra  just  be- 
low it,  cro.s.sfd  bji  the  inferior  thyroid  artery  and,  on  the  h'ft  side,  by 
the  thoracic  duct.  It  is  less  often  tied  than  formerly.  Jieloir  the  omo- 
hyoid the  carotid  artery  lies  more  and  more  deeply,  as  we  follow  it  to 
the  base  of  the  neck,  being  overlapped  in  front  by  the  sternohyoid  and 
sternothyroid  muscles  and  to  some  extent  by  the  thyroid  body, 
especially  if  the   latter  is  enlarged.      Near  its  hirer  end  the  anterior 


128  THE  HEAD   AND  NECK. 

jugular  vein  crosses  in  front  of  it  and  the  inferior  thyroid  artery  and 
recurrent  laryngeal  nerve  behind  it. 

The  carotid  sheath,  (Jerired  from  the  deep  layer  of  the  deep  cervical 
fascia,  encloses  the  internal  jugular  rei)i  and  the  vagus  nerve  in  addi- 
tion to  the  artery.  The  sheath  should  be  opened  from  the  inner  side 
to  avoid  the  thin-walled  vein  which  is  external  and,  being  nearly 
twice  the  size  of  the  artery,  overlaps  the  latter  anteriorly.  On  the 
right  side  the  rei)i,  which  is  commonly  larger  than  that  on  the  left,  be- 
comes a  little  separated  from  the  artery  at  the  root  of  the  neck  while 
on  the  left  side  the  vein  overlaps  the  artery  still  more  at  this  point. 
Although  each  of  the  three  occupants  of  the  sheath  has  its  own 
special  investment  there  is  danger  of  wounding  the  vein  in  passing  the 
aneurisni  needle  and  to  avoid  this  danger  the  latter  is  passed  from 
without  inward  after  carefully  separating  the  vein  and  artery. 

In  exposing  the  sheath  of  the  carotid  the  descendens  noni  nerve  is 
found  in  front  of  it,  inclining  gradually  from  the  outer  to  the  inner 
side.  Care  should  be  taken  to  avoid  it  as  it  supplies  the  infrahyoid 
muscles.     It  is  sometimes  found  within  the  sheath. 

As  before  stated  the  external  carotid  is  now  ligated  for  many  condi- 
tions for  which  the  common  carotid  was  formerly  tied.  Thus  it  is 
ligated  for  wound  or  aneurism  of  its  branches,  as  a  preliminary  measure 
in  certain  operations  (like  excision  of  the  parotid,  maxilla,  etc.)  and  as 
a  palliative  measure  in  malignant  neoplasms  to  starve  them  or  prevent 
hemorrhage.  For  the  latter  purpose  excision  is  more  effective  than 
ligature.  Ligature,  and  especially  excision,  of  the  external  carotid  is 
less  easy  but  safer  and  more  satisfactory  than  ligature  of  the  common 
carotid. 

The  line  of  the  external  carotid  inclines  forward  from  the  line  of 
the  sternomastoid  to  reach  a  point  beneath  the  augle  of  the  jaw.  In 
the  natural  position,  when  the  angle  of  the  jaw  about  touches  the  sterno- 
mastoid, the  line  of  the  artery  nearly  corresponds  to  the  anterior  border 
of  the  muscle,  but  in  the  extended  position  of  the  head,  in  which  the 
operation  is  done,  the  line  of  the  artery  is  from  the  angle  of  the  jaw 
to  the  sternomastoid  at  the  upper  border  of  the  thyroid  cartilage. 

The  incision  for  ligature  or  excision  may  be  made  in  this  line  or 
across  it,  in  the  line  of  Kocher's  normal  incision  (p.  125),  In  its  loirer 
part  the  artery  is  corapariatively  superficial,  being  covered  by  the  same 
layers  which  cover  the  upper  part  of  the  common  carotid  (p.  127),  but 
it  soon  becomes  more  d('ej)ly  j^laced  and  passes  beneath  the  digastric 
and  stylohyoid  muscles  and  then  internal  to  and  within  the  parotid 
gland.  Below  the  digastric,  which  crosses  it  about  IJ  inch  above  its 
commencement,  it  is  crossed  by  the  hypoglossal  nerve  and  below  this 
by  the  facial  and  lingual  veins,  usually  as  a  common  trunk  which  is 
often  joined  by  the  superior  thyroid  vein.  The  place  of  election  for 
ligature  is  between  the  superior  thyroid  and  the  lingual  branches,  or 
opposite  the  tip  of  the  great  cornu  of  the  hyoid  bone.  Through  the 
same  incision  the  four  lower  branches  of  the  external  carotid  can  be 
ligated  at  their  origin. 


ASPIRATION  OF  A  HI  INTO  VEINS.  129 

In  the  first  part  of  its  course  the  external  carotid  is  situated  internal 
(mesial)  and  anterior  to  the  internal  carotid,  in  the  loose  connective 
tissue  in  whicli  both  are  lodged,  hence  the  (juestion  may  arise  whether 
the  vessel  exposed  is  the  internal  or  external  carotid.  The  following 
jjointi<  help  us  to  ditifinf/ui.sh  the  external  carotid,  (1)  the  presence  of 
branches  ;  (2)  the  stoppage  of  pulsation  in  its  branches  from  compres- 
sion of  the  artery;  (3)  contact  with  the  hypoglossal  nerve  which  crosses 
it  just  below  tlie  origin  of  the  occipital  l)ranch,  and  (4)  its  near  rela- 
tion to  the  great  cornu  of  the  hyoid. 

In  pai<!<in(j  the  (tneurism  needle  care  is  needed  to  avoid  the  superior 
laryngeal  nerve  which  passes  beneath  it  in  this  situation.  The  artery 
may  also  be  tied  beneath  or  above  the  digastric  but  it  lies  dee})er  here 
and  is  more  difficult  to  expose.  Some  distance  above  the  muscle  the 
glossopharyngeal  nerve  passes  obliquely  beneath  the  artery.  For  the 
various  anomalies  and  variations  of  the  external  carotid  descriptive 
text-books  may  be  consulted  but  one  may  be  mentioned  which  I  have 
found  in  a  preliminary  ligature  of  this  vessel,  /.  e.,  the  absence  of  an 
external  carotid  trunk  and  the  giving  off  of  the  branches  in  an  axis 
manner. 

The  internal  carotid  may  be  exposed  and  llf/ated  in  much  the  same 
manner  and  with  the  same  precautions  as  the  common  carotid,  of  which 
it  appears  to  be  the  continuation  as  to  its  course  and  relations.  What 
has  been  said  above  as  to  the  relations  of  the  common  carotid  and  its 
branches  is  equally  and  more  frequently  useful  in  the  numerous  oper- 
ations for  various  conditions  in  which  these  vessels  are  exposed  and 
avoided,  as  in  tubercular  1 1/ mphadenoma  of  the  neck,  etc. 

The  internal  jugular  and  the  other  veins  of  the  neck,  as  -well  as  the 
subclavian  and  axillary  veins,  are  subject  to  the  respiratory  wave  for 
venous  pulse).  This  is  indicated  by  their  being  more  or  less  emptied 
in  inspiration  and  distended  in  expiration  and  is  due  to  the  alternately 
decreased  and  increased  intrathoracic  pressure  acting  on  the  right  heart 
and  the  venous  trunks.  When  one  of  these  veins  is  wounded  air  is 
liable  to  be  drawn  in  during  the  inspiratonj  asjtiration  of  its  contents 
provided  the  ^\ound  is  dry  or  the  vein  is  not  immediately  compressed 
between  the  wound  and  the  heart.  Nothing  prevents  the  passage  of  this 
air  to  the  right  auricle  of  the  heart.  Hence  pressure  should  be  at  once 
made  at  the  wound  of  the  vein  or  on  its  cardiac  side.  Asj)ir(dion  of 
air  into  veins  is  not  so  frequent  an  accident  as  is  generally  su])posed, 
and  as  might  be  expected  from  the  above.  It  is  not  likely  to  happen 
if  the  peripheral  flow  of  blood  to  the  wounded  spot  is  unobstructed,  or 
if  the  wall  of  the  vein  is  healthy  and  its  wound  is  not  held  o])en,  for 
then  atmospheric  pressure  causes  it  to  collapse.  It  is  farored  by  tlie 
elevation  of  the  wounded  part  and  it  may  occur  beyond  the  limits  of 
the  venous  pulse.  Wiien  larr/e  (unoHnt.s  of  air  are  aspirated  it  may 
cause  dc'it/i  rapidly  by  over-distension  and  paralysis  of  the  right  heart, 
or  more  slowly  by  asphvxia  from  air  embolism  of  the  ])ulmonary  vessels. 
The  entrance  of  smaller  (|uantities  of  air  is  usually  recovered  from. 

The  cervical  portion  of  the  sympathetic  gangliated  cord  lies  dose  be- 
9 


130  THE  HEAD   AND  NECK. 

hind  the  carotid  sheath  and  in  front  of  the  prevertebral  fascia.  It  lies 
slightly  internal  to  the  vagns  nerve  which  is  within  the  sheath.  It  con- 
sists of  three  composite  ganglia  united  by  intervening  nerve  cords. 

The  superior  cervical  sympathetic  ganglion  (2.5  to  3.75  cm.  long) /?Vs 
in  front  of  the  second  and  third  cervical  transverse  processes.  It  is  con- 
nected above  with  the  carotid  and  cavernous  plexuses,  below  with  the 
smaller  middle  or  thyroid  ganglion,  situated  where  the  cord  crosses  in 
front  of  and  behind  the  inferior  thyroid  artery  at  the  level  of  the  sixth 
cervical  vertebra.  The  mid<lle  is  connected  with  the  inferior  ganglion 
by  cords  which  pass  both  behind  and  in  front  of  the  subclavian 
artery.  The  inferior  ganglion,  larger  than  the  middle,  is  deeply  p/rtced 
between  the  seventh  cervical  transverse  process  and  the  neck  of  the 
first  rib,  behind  the  vertebral  artery. 

As  far  as  we  now  know  the  functions  of  the  cervical  si/mpathctic  it 
contains  dilator  fibers  of  the  pupil,  motor  fibers  of  the  involuntary 
muscles  of  the  orbit  and  eyelid,  vaso-motor  fibers  of  the  head,  accelera- 
tor fibers  of  the  heart,  besides  secretory  fibers  of  the  salivary  glands. 
From  theoretical  considerations  the  excision  of  the  superior  or  all  the 
cervical  ganglia  has  been  proposed  for  glaucoma,  exophthalmic  goitre, 
and  epilepsy. 

The  superior  gnnglion  alone  requires  removal  for  glaucoma  and  it  is 
folloiced  by  contraction  of  the  pupil,  retraction  of  the  globe,  some 
ptosis  and  the  diminution  of  the  ocular  pressure  (see  p.  71).  The 
contraction  of  the  pupil  is  temporary,  lasting  only  a  few  days  and  so 
is  usually  the  ptosis.  As  the  superior  ganglion  inhibits  the  vaso-con- 
strictors  of  the  carotid  region  only,  the  inferior  ganglion,  which  does 
the  same  for  the  vertebral  region,  must  also  be  removed  to  alter  the 
cerebral  circulation  in  epilepsy  and  improve  the  nutrition  of  the  brain, 
by  substituting  hyperiemia  for  anaemia.  The  results  in  epilepsy  have 
not  been  very  satisfactory.  For  e.ropldhahnic  goitre  the  resection  of 
the  superior  ganglion  for  exophthalmos  and  the  middle  and  inferior 
for  the  goitre  and  tachycardia  have  given  some  encouraging  results. 
Hence  for  epilepsy  and  Graves'  disease  the  resection  of  the  entire 
cervical  sympathetic  is  advisable  but  from  the  anatomical  relations 
above  given  it  is  evident  that  the  operation  on  the  middle  and  inferior 
ganglia  is  one  of  great  delicacy.  The  cervical  sympathetic  may  be 
exposed  by  an  incision  along  the  anterior  or  posterior  border  of  the  ster- 
nomastoid  more  readily  than  might  be  supposed.  Unilateral  division  of 
the  vagus  nerve  may  be  made  without  danger  to  life  or  even  without 
disturbance  to  the  ])aticnt. 

The  Hyoid  Bone. — Fracture  of  this  is  rare  but  it  may  occur  in  hang- 
ing or  from  blows,  falls,  throttling  or  even  muscular  action.  Its  usual 
situation  is  at  or  near  the  junction  of  the  great  cornu  with  the  body  of 
the  bone.  It  cr«f.sr.spain  on  speaking,  swallowing,  opening  the  mouth, 
moving  the  tongue,  or  on  pressure.  It  is  not  often  serious  of  itself 
but  its  associated  injuries  may  be  fatal. 

Extending  between  the  upper  border  of  the  thyroid  cartilage  and 
the  upper  and  posterior  margin  of  the  hyoid  bone  is  the  thyrohyoid 


CUT  THROAT   WOUSDS.  3  31 

membrane,  about  3—4  cm.  in  hoiglit.  Owing  to  its  attachment  to  the 
sui)(rior  border  of  the  hyoid  the  larynx  may  be  drawn  up  behind  the 
latter  bone.  In  front  of  the  membrane,  and  between  it  and  the  b;iek 
of  the  hvoid  bone  and  the  integument  and  fascia  below  it,  is  the  thyro- 
hyoid bursa  which  wlien  cystic  forms  a  median  tumor  just  beneath  the 
hyoid.  If  this  should  be  opened,  as  in  case  of  suppuration,  a  fistula 
is  likely  to  result  unless  the  lining  membrane  has  been  excised,  for  the 
constant  movements  of  the  parts  in  swallowing  j)revent  the  walls  of 
the  cyst  from  adhering  t(jgether.  Meniolhj  the  membrane  is  subcu- 
taneous except  for  the  intervening  cervical  fascia,  laterally  it  is  covered 
by  tiie  thyrohyoid  and  sternohyoid  muscles. 

Behind  the  thyrohyoid  meml)rane  and  separating  it  from  the  epi- 
glottis is  a  mass  of  fatti/  conneciive  tissue  limited  superiorly  by  the 
raucous  membrane  at  the  base  of  the  tongue.  Through  this  tissue 
and  the  thyrohyoid  membrane  the  transverse  incision  is  carried  in  sub- 
hyoid pharyngotomy,  keeping  close  beneath  the  hyoid  bone  to  avoid  the 
■superior  larijiifjeid  nerve  (internal  branch)  which  pierces  the  membrane 
on  each  side.  As  this  is  the  sensory  nerve  of  the  larynx  wounding  it 
increases  the  risk  of  foreign  substances  passing  through  the  larynx, 
which  involves  the  danger  of  aspiration  pneumonia.  By  this  operation 
we  may  expose  and  operate  upon  the  larynx  above  the  vocal  cords, 
especially  posteriorly,  and  the  lower  part  of  the  pharynx. 

It  is  through  this  thyrohyoid  membrane  and  its  over-  and  under- 
lying parts  that  cut  throat  wounds  are  most  likely  to  occur.  In  such 
cases  the  anterior  jugular  vein,  superior  thyroid  artery  and  nerve  and, 
if  near  the  hyoid  bone,  perhaps  the  lingual  artery  would  be  divided, 
besides  several  muscles,  etc.  In  a  deep  wound  the  pharynx  would  be 
opened  and  the  epiglottis  cut  near  its  base.  The  latter  are  serious  com- 
plie(dions  for  the  free  end  of  the  epiglottis  may  obstruct  the  glottis  and 
the  blood  flowing  into  the  larynx  and  trachea  may  also  cause  asphyxia. 
Suicidal  throat  wounds  made  i)y  right-handed  persons  are  generedly 
oblique,  passing  from  the  left  downw^ard  and  to  the  right,  and  the  first 
part  of  the  wound  is  often  shallow.  If  the  wound  be  above  the  hyoid 
bone,  the  anterior  jugular  vein,  lingual  artery,  branches  of  the  ficial 
artery,  the  iiypoglossal  and  lingual  nerves  and  the  submaxillary  gland, 
besides  several  muscles,  would  be  cut.  Among  the  divided  muscles 
are  those  attaching  the  tongue  to  the  jaw  so  that  the  tongue  is  liable  to 
fall  back  upon  the  larynx  and  cause  suffocation.  The  tongue  itself 
may  be  cut  and  the  floor  of  the  mouth  freely  opened. 

Next  in  frequency  to  wounds  in  the  thyrohyoid  space  are  those 
involving  the  trachea  or  larynx  in  which  the  anterior  jugular  vi-in, 
thyroid  gland,  superior  and  inferior  thyroid  arteries  and  veins,  middle 
thyroid  veins,  recurrent  laryngeal  nerves,  trachea  and  (esophagus, 
besides  the  infrahyoid  muscles,  are  cut.  There  is  danger  of  blood 
getting  into  the  trachea  and  bronchi  in  sufficient  quantity  to  produce 
suffocation.  When  the  trachea  is  severed  or  widely  opened  the  voice 
is  lost. 

In  all  such   wounds   of  the  neck,  suicidal   or  otherwise,  the  great 


132 


THE  HEAD  AND  NECK. 


vessels  often  escape  in  a  wonderful  manner,  being  protected  in  part  by 
their  depth  and  mobility,  and  in  part  by  the  projecting  thyroid  carti- 
lages and  by  the  contraction  of  the  sternomastoid  muscle.  Of  course 
in  some  cases  the  great  vessels  are  wounded,  usually  with  a  rapidly 
fatal  result.  In  some  cases  of  gunshot  and  'punctured  wounds  the 
vessels  seem  to  have  been  pushed  aside  and  to  have  owed  their  safety 
to  their  mobility.  The  great  vessels  are  more  easily  wounded  in 
wounds  across  the  cricothyroid  space  or  the  upper  part  of  the  trachea 
than  in  wounds  made  elsewhere  in  the  neck  with  equal  force.  Wounds 
at  the  side  of  the  neck  have  involved  a  large  part  of  the  hrachial  plexus 
without  other  important  structures.  The  chief  dangers  of  wounds  of 
the  neck  are  hemorrhage  and  suffocation,  the  latter  from  blood  in  the 
trachea  and  bronchi  or  from  obstruction  of  the  glottis  by  the  falling 
back  of  the  tongue  or  the  wounded  epiglottis. 

The  larynx  in  its  median  position  below  the  thyrohyoid  membrane 
can  usually  be  readWy  felt,  especially  in  males  in  whom  it  is  larger,  so 
that  it  stands  out  between  the  two  sternomastoids.  The  most  promi- 
ment  part  is  the  anterior  mesial  border  of  the  thyroid  cartilage,  2-3 

Fig.  33. 


EPIGLOTTIS 


ARVTENO-EPI- 

GLOTTIC    FOLD 

PYRIFORM     POUCH 

CARTILAGE    OF 

WRISBERG 

CARTILAGE    OF 

SANTORINI 


FALSE    VOCAL 

CORD 
VENTRICLE 

TRUE    VOCAL 
CORD 


ARYTENOID 

COMMISSURE 


Larynx  viewed  from  above,  the  vocal  cords  and  arytenoid  cartilages  widely  separated. 

(ZUCKEKKANDL.  ) 

cm.  in  height,  whose  upper  angle  is  known  as  the  pomum  Adami  or 
Adam's  apple.  A  bursa  has  been  described  in  front  of  this  promi- 
nence by  Bechard.  In  women  and  children,  in  whom  the  neck  is  more 
rounded  and  the  larynx  is  smaller,  the  latter  is  less  prominent  but  is 
usually  distinctly  felt,  and  is  an  important  landmark. 

The  relative  position  of  the  larynx  varies  with  the  position  of  the 
neck  and  the  age  of  the  })atient.  Thus  the  louder  border  of  the  cricoid 
cartilage  varies  from  a  point  opposite  the  fifth  to  one  opposite  the  sev- 
enth cervical  vertebra,  being  higher  in  the  young  and  when  the  neck 
is  extended.  In  the  median  line  the  larynx  is  covered  only  by  the 
skin  and  cervical  fascia  (the  anterior  and  middle  layers  blended  into 
one),  laterally  by  the  infrahyoid  muscles  and  the  thyroid  gland.  The 
superior  aperture  of  the  larynx,  or  the  space  between  the  aryteno- 
epiglottic  folds,  corresponds  to  the  superior  border  of  the  thyroid  car- 


THE   GLOTTIS.  133 

tilage,  the  (jhAtin,  to  the  junction  of  the  superior  and  middle  thirds  of 
its  anterior  border,  the  laryngeal  pouches  to  about  its  superior  third. 

With  the  laryngoscope  may  be  seen  the  triangular  superior  aperture 
of  the  larynx  placed  very  obliquely  from  above  and  in  front  downward 
and  backward.  Its  base  is  at  the  epiglottis  in  front,  its  aides  are 
formed  by  the  aryteno-epiglottic  folds  in  which  are  two  eminences 
corresponding  to  the  cornicula  and  cuneiform  cartilages,  and  its  apex 
is  at  the  arytenoid  commissure  of  mucous  membrane.  Between 
each  aryteno-epiglottic  fold  and  the  ala  of  the  thyroid  cartilage  is  the 
shallow  depression  of  the  pyriforni  sinus.  More  deeply  are  seen  the 
superior  or  false  and  the  inferior  or  hme  vocal  cords  with  the  ventricle 
between  the  two  pairs  of  cords.  Below  the  glottis  a  little  of  the 
cricoid  cartilage  and  more  or  less  of  the  anterior  tracheal  w'all  is 
visible  and,  if  the  glottis  is  widely  dilated,  even  the  hijurcation  of  the 
trachea  may  be  dimly  seen.  The  mirror  being  tilted  the  image  of 
the  epiglottis  is  in  its  upper  and  anterior  part,  that  of  the  arytenoids 
in  the  lower  and  posterior  part,  but  that  of  either  vocal  cord  is  on  the 
side  to  w'hich  it  actually  belongs. 

The  glottis  (Figs.  21,  33)  is  the  narroivest  pjart  of  the  interior  of  the 
larynx  measuring  about  one  inch  antero-posteriorly  in  the  adult  male, 
and  about  three  fourths  of  that  in  the  female  and  in  the  male  before 
puberty.  Approximately  the  anterior  two  thirds  of  the  glottis  consists 
of  the  true  vocal  cords,  the  posterior  third  of  the  interval  between  the 
arytenoid  cartilages,  covered  by  mucosa.  The  transverse  diameter 
may  equal  half  its  length  in  extreme  dilatation. 

On  account  of  its  narrow  caliber  foreign  bodies  of  the  most  varied 
character  may  be  arrested  here,  either  above  or  in  the  rima  of  the 
glottis  according  to  their  size.  I  recently  removed  from  a  one-year- 
old  baby  through  a  high  tracheotomy  two  pieces  of  cg^  shell  which 
were  caught  in  the  glottis  and  hung  down  below  it.  The  mucosa  of 
the  larynx,  supplied  by  the  superior  laryngeal  nerve,  is  so  sensitive 
that  it  acts  as  asenti)iel  at  whose  warning  the  glottis  closes  to  keep  out 
foreign  bodies,  but  it  is  sometimes  taken  unawares  and  lets  a  foreign 
body  through  into  the  trachea.  The  danger  of  such  foreign  bodies  in 
the  larynx  or  trachea  is  not  so  much  due  to  the  mechanical  obstructi<)n 
as  to  the  reflex  spasm  of  the  glottis  which  they  excite. 

A  peculiar  spasm  of  the  ///o/Z/.v  of  central  nervous  origin,  perhaps  due 
to  indigestible  food  or  other  reflex  cause,  occurs  in  infancy  under  the 
name  of  laryngismus  stridulus  or  laryngeal  asthma.  A  similar  condi- 
tion of  spasm  of  the  glottis  in  adults  may  be  due  to  the  pressure  of  an 
aneurism  or  a  tumor  on  the  recurrent  laryngeal  nerve.  Such  pressure 
in  time  paralyzes  the  nerve  so  that  the  vocal  cord  on  the  affected  side 
cannot  l)e  approximated  and  consecpicntly  the  voice  is  hoarse  or  lost, 
a  characteristic  symptom  of  many  aneurisms  of  the  aortic  arch.  The 
opposite  cord  may  however  be  made  to  reach  beyond  the  median  line 
in  the  effort  at  compensation. 

The  caliber  of  the  rima.  g/affidis  may  be  diminished  as  the  result  of 
strictures  from   syphilitic,  tubercular  or  diphtheritic   ulceration  which 


134  THE  HEAD  AND  NECK. 

require  the  long-continued  use  of  an  intubation  tube  or  sometimes  a 
more  radical  operation. 

The  shape  of  the  glottis  varies  from  an  extremely  narrow  vibrating 
slit,  in  the  production  of  a  high  note,  to  an  elongated  narrow  triangle 
with  the  apex  forward,  in  quiet  breathing,  or  a  lozenge-shaped  figure 
with  a  truncated  posterior  angle  in  deep  respiration.  These  changes 
are  due  to  the  approximation  or  separation  of  the  sides  of  the  glottis 
by  means  of  the  approximation  or  separation  of  the  arytenoid  carti- 
lages, and,  in  the  production  of  the  wider  lozenge-shape  opening,  by 
the  rotation  of  their  anterior  angles,  to  which  the  vocal  cords  are 
attached.  The  glottis  is  also  dosed,  after  inspiration,  to  fix  the  dia- 
phragm in  efforts  of  expulsion,  as  in  defsecation,  urination,  vomiting 
and  parturition. 

The  mucosa  of  the  true  vocal  cords  is  covered  by  a  thin  stratified 
epithelium.  There  is  no  loose  submucous  connective  tissue,  hence 
there  is  little  or  no  chance  of  acute  oedema  of  the  glottis.  The  so- 
called  "oedema  of  the  glottis"  occurs  in  the  aryteno- epiglottic  folds 
where  there  is  an  abundance  of  submucous  tissue.  This  may  rapidly 
swell  in  case  of  laryngitis  or  irritation  by  heat,  caustics,  injury  or 
neighboring  inflammatory  conditions,  and  cause  obstruction  of  the 
superior  aperture  of  the  larynx,  with  dyspnoea.  The  mucosa  is  thickest 
and  the  submucosa  most  abundant  in  the  aryteno-epiglottic  folds,  the 
ventricles,  the  false  vocal  cords  and  the  under  surface  of  the  epiglottis, 
in  the  order  given,  and  the  degree  of  congestion  and  swelling  in  acute 
laryngitis  varies  correspondingly.  The  result  of  the  swelling  is  a 
croupy  cough  and  hoarseness,  with  dyspnoea  in  severe  cases  from 
obstruction  or  spasm. 

Laryngeal  polypi  of  various  kinds,  either  pedunculated  or  sessile, 
may  grow  on  the  vocal  cords  or  other  parts  of  the  larynx  and  cause 
aphonia,  cough  and  more  or  less  difficulty  in  breathing.  They  may 
be  removed  through  the  mouth,  with  the  aid  of  the  laryngoscope, 
through  an  anterior  pharyngotomy  or  by  thyrotomi/.  The  latter  consists 
of  a  median  splitting  of  the  thyroid  cartilage  which  must  be  done  exactly 
in  the  median  line  so  that  the  opening  into  the  larynx  shall  be  between 
the  vocal  cords,  otherwise  there  is  great  danger  of  permanently  im- 
pairing vocalization.  This  operation  may  also  be  applied  to  the  re- 
moval of  impacted  foreign  bodies. 

The  thyroid,  cricoid  and  arytenoid  cartilages  are  composed  of  hyaline 
cartilage  and,  like  other  structures  composed  of  this  variety  of  carti- 
lage, are  liable  to  ossification,  especially  in  males  after  middle  life. 
It  occurs  first  in  the  thyroid  and  cricoid  cartilages,  commences  near 
their  articulation  and  renders  the  larynx  more  liable  to  fracture.  The 
latter  occurs  from  lateral  or  anterior  compression  by  blows,  falls, 
throttling,  etc.  Fracture  is  therefore  more  common  in  males  and  in 
the  thyroid  cartilage  on  account  of  its  size,  shape  and  prominence. 
The  thyroid  cartilage  is  commonly //yi-c/k/yy/  at  or  near  the  median  line. 
According  to  Dr.  Rambaud  the  line  of  fracture  is  usually  to  one  side  of 
the  median  line,  owing  to  the  fact  that  the  two  aire  of  the  thyroid  are 


THE  TRACHEA.  135 

united  in  front  by  a  thin  median  strip  of  cartilage  at  whose  junction 
with  one  of  the  alfe  the  fracture  occurs.  Fracture  of  the  cricoid  is 
less  common  and  more  serious,  as  it  re(|uires  more  violence.  Fracture 
of  the  larynx  is  dangerous  on  account  of  the  liability  to  di/.yjncea  due 
to  the  aspiration  of  blood,  spasm  of  the  glottis,  displacement  of  the 
fragments  and  oedema  of  the  glottis.  Hence  in  most  cases  tracheotomy 
should  be  promptly  done.  The  epjir/lottis,  like  other  elastic  cartilages,  is 
not  liable  to  ossification  but  it  is  a  favorite  site  ior  syphilitic  ulceration. 

Excision  of  the  larynx,  a  comparatively  recent  operation,  has  been 
practiced  a  considerable  number  of  times  and  almost  always  for  malig- 
nant disease.  It  gives  a  high  mortality  and  a  ])oor  prognosis  as  to 
recurrence.  After  a  preliminary  tracheotomy  and  exposure  by  a  free 
median  incision  the  larynx  is  freed  laterally  from  the  sternothyroid 
and  thyrohyoid  muscles  and  more  posteriorly  from  the  stylo-  and 
palatopharyngei  and  the  inferior  constrictor  muscles.  The  superior 
and  inferior  laryngeal  nerves  are  divided,  the  branches  of  the  like 
named  arteries  and  the  ligaments  connecting  the  epiglottis  to  the 
tongue  and  hyoid  bone.  Then  detaching  it  from  the  trachea  or  the 
thyrohyoid  membrane  the  larynx  is  separated  from  the  pharynx  and 
oesophagus  behind  it,  either  from  below  up  or  above  down,  care  being 
taken  not  to  "  button-hole "  the  oesophagus.  Occasionally  only  one 
half  of  the  larynx  is  excised. 

Laryngotomy  (cricotomy),  or  the  opening  of  the  larynx  through  the 
cricothyroid  membrane,  is  sometimes  performed  in  place  of  tracheotomy 
on  account  of  the  ease  and  rapidity  of  its  jjerformance.  It  is  not 
a])plicable  to  children  under  puberty  on  account  of  the  narrowness  of 
the  cricothyroid  space,  which  in  the  adult  is  at  most  only  about  one 
half  inch  in  height.  The  cricothyroid  branches  of  the  superior  thyroid 
arteries  anastomose  across  this  space  and,  though  usually  small,  they 
occasionally  cause  serious  and  even  fatal  hemorrhage,  which  may  be 
obviated  by  dividing  the  membrane  transversely  or  by  tearing  the 
artery  between  two  forceps.  An  objection  to  the  operation  is  the 
proximity  of  the  vocal  cords  so  that  it  is  unsuited  for  cases  where  the 
tube  is  to  be  worn  for  long.  In  adults,  to  whom  alone  the  operation  is 
applicable,  it  is  not  advisable  to  divide  the  cricoid  cartilage  to  gain 
more  room  on  account  of  the  possibility  of  its  being  ossified  and  the 
little  added  room  that  it  jrives. 

The  lymphatics  of  the  larynx  pass  to  the  deep  cervical  glands.  Of 
the  nerves  of  the  larynx  the  superior  sujiplies  sensatio)i  to  the  mucosa 
and  motor  fibers  to  the  cricothyroid  muscle,  which  makes  the  cords 
tense.  The  arytenoid  muscle  is  supplied  both  by  this  and  the  recur- 
rent laryngeid,  which  supplies  all  the  other  muscles. 

Trachea. — About  Iialf  or  2|  inches  of  the  trachea  is  in  the  neck, 
between  the  cricoid  cartilage,  opposite  the  sixth  cervical  vertebra,  and 
the  epistcrnal  notch.  This  length  varies  with  the  age,  and  the  length 
and  position  of  the  neck.  Thus  in  extension  of  the  neck  it  may  be 
increased  by  three  fourths  of  an  inch  in  its  cervical  portion  and  one 
inch    (Branne)    altogether,    owing    to    its    elasticity.     This    elasticity 


136  THE  BEAD  AND  NECK. 

allows  it  to  accommodate  itself  to  the  movements  of  the  neck  and  also 
causes  the  lower  end  to  retract  when  it  is  severed.  The  retraction  is 
favored  by  the  loose  connective  tissue  in  which  it  lies  and  this  also  allows 
of  considerable  lateral  mobility.  This  mobility  is  greater  in  children. 
It  allows  the  trachea  to  escape  from  injury  or  the  pressure  of  tumors 
on  one  side  of  it,  and  adds  to  the  difficulties  of  tracheotomy.  As  the 
trachea  passes  somewhat  backward  as  it  descends  its  upper  part  is  more 
superficial,  hence  when  possible  tracheotomy  should  be  performed  here, 
for  not  only  is  it  deeper  below  but  its  relations  are  more  complicated. 

Relations  of  Overlying  Parts.  (Fig.  35.) — Above  the  thyroid  isth- 
mus, which  lies  in  front  of  the  second,  third  and  fourth  tracheal  carti- 
lages, the  sternohyoid  and  sternothyroid  muscles  are  separated  by  a 
slight  interval  and  the  superficial  and  middle  layers  of  deep  cervical 
fascia  form  practically  a  single  layer  in  the  median  line.  The  levator 
glanduhe  thyroidete  muscle  and  the  pyramidal  lobe  of  the  thyroid  when 
present  lie  in  front  of  the  trachea.  As  the  thyroid  isthmus  may  leave 
uncovered  above  it  but  a  single  tracheal  ring  it  must  be  retracted  doivn- 
roard.  To  permit  this  the  fascia  connecting  it  to  the  cricoid  cartilage 
should  be  divided  by  a  transverse  incision  over  the  latter  and  then  its 
downward  retraction  is  easy.  In  children  the  thyroid  isthmus  is  little 
more  than  connective  tissue  and  may  be  ignored  or  divided  between  two 
ligatures  and  the  latter  may  be  done  in  the  adult.  Abnormal  branches 
of  the  superior  th3'^roid  artery  or  twigs  of  it  to  the  jiyramidal  process, 
when  present,  may  cross  the  upper  tracheal  rings,  and  a  communicating 
branch  between  the  superior  thyroid  veins  may  cross  at  the  upper  border 
of  the  isthmus. 

Below  the  thyroid  isthmus  the  superficial  and  middle  layers  of  the 
deej)  cervical  fascia  are  separated  from  one  another  by  an  interval  filled 
"with  loose  connective  tissue  and  fat,  in  which  there  is  a  transverse 
anastomosis  between  the  anterior  jugular  veins,  just  above  the  sternum. 
Below  the  thyroid  gland  the  superficial  lai/er  splits  into  two  laifers 
attached  to  the  anterior  and  posterior  borders  of  the  episterual  notch 
and  enclosing  a  triangular  interval  so  that  there  are  three  fascial  layers 
to  incise  at  this  level.  Beneath  the  middle  layer  of  the  deep  fascia  is 
a  layer  of  fatty  connective  tissue  in  which  the  inferior  thyroid  veins, 
the  thyroidea  ima,  when  present,  and,  in  infants  under  two  years  of  age, 
the  upper  1  cm.  of  the  thymus  gland  lies  in  front  of  the  trachea.  At 
the  very  root  of  the  neck  the  left  innominate  vein  crossing  the  trachea 
may  extend  up  above  the  sternum,  especially  when  there  is  venous 
congestion  or  when  the  neck  is  extended,  both  of  which  conditions  are 
usually  present  when  tracheotomy  is  performed.  The  carotids  crossing 
the  trachea  antero-laterally  may  occasionally  overlap  it  in  front  to  an 
abnormal  degree  and  the  left  common  carotid  when  it  arises  from  the 
innominate  may  cross  the  trachea  above  the  sternum.  The  infrahyoid 
muscles  are  here  in  close  contact   and    the  trachea  is   more  movable. 

Tracheotomy  is  called  high  or  low  according  as  it  is  above  or  below 
the  isthmus  of  the  thyroid  body.  The  above  facts,  in  addition  to  the 
depth  from  the  surface  and  the  greater  danger  of  broncho-pneumonia 


PLATE   XI 


STE  R  NOH YOl  D 
MUSCLE 


LINGUAL    ARTERY 


SUP.   THYROI  D 
ARTERY 


SUP.    LARYNGEA 
ARTERY 


THYROHYOID 
MEMBRANE 


/    I^RICOTHYROID 
ARTERY 


j    THYROID 
GLAND 


INF     THYROID 
VEINS 


Superficial  vessels  of  the  infrahyoid  region,  around 
the  larynx,  thyroid  and  trachea.     (Merkel.) 


FIG.  35. 


THYROID 


COMMON    CAROTID 

ARTERY 
VAGUS     NERVE 
RECURRENT 

LARYNGEAL 

NERVE 

SYMPATHETIC 
GANGLION 


Ct'oss  section  of  thyroid  body,  trachea  and  oesophagus, 
showing  their  relations.      (Testut. ) 


TRACHEOTOMY.  137 

and  of  the  sinking'  of  pns  into  the  mediastinum,  make  the  high  opera- 
tion always  to  be  preferred. 

In  either  operation  the  nee  I:  should  ha  full  ij  extended,  for  this  .-teadies 
the  traehca,  makes  it  more  superficial,  lengthens  the  neck  and  the  por- 
tion of  the  trachea  in  the  neck  and  makes  tense  the  structures  in  front. 
The  chin  is  held  in  the  same  longitudinal  line  with  the  episternal  notch 
and  the  incision  is  made  e.roffli/  in  the  median  line.  The  cervical  fa-icia 
should  be  well  and  freehj  dicided  to  avoid  the  not  uncommon  accident 
of  passing  the  tube  between  the  fascia  and  the  trachea.  The  trachea 
should  be  steadied  from  above  by  a  sharp  hook  in  the  median  line  as 
a  guide  to  the  latter  and  to  the  opening  when  made.  Cases  are  reported 
where,  from  lack  of  such  precaution,  the  trachea  has  been  opened  from 
the  side  or  behind  or  even  through  the  oesophagus  and  where  the  open- 
ing when  made  could  not  be  readily  found  again.  The  opening  should 
be  made  by  a  thrust  of  the  knife  to  insure  the  penetration  of  the  lining 
mucosa  to  avoid  the  mistake  of  passing  the  tube  into  the  trachea  between 
the  mucosa  and  the  fibro-cartilaginous  framework. 

The  diameter  of  the  trachea  varies  tvith  the  age  and  to  some  extent 
individually  and  is  of  importance  with  reference  to  the  size  of  the 
tracheotomy  tube  to  be  used.  In  the  adult  cadaver  the  greatest  trans- 
verse diameter  may  vary  between  three  quarters  and  one  inch  but  in  the 
living  subject  it  is  less.  According  to  the  observations  of  Symington 
and  Guersant  the  following  diameters  of  the  tube  are  suited  to  the  ages 
given.  Under  1 J  years,  4  mm.;  H  to  2  years,  5  ram.;  2  to  4  years,  6 
mm.;  4  to  8  years,  8  mm.;  8  to  12  years,  10  mm.;  12  to  15  years,  12 
mm.;  adults,  12  to  15  mm.  The  tube  should  not  be  too  curved  lest 
the  pressure  of  its  sharp  end  cause  an  ulceration  into  the  innominate 
vein  or  artery  or  the  common  carotid  and  occasion  a  fatal  hemorrhage. 
I  have  known  of  one  sncli  case  and  several  are  recorded. 

The  difficulties  of  tracheotomy  in  children  depend  upon  the  shortness 
of  the  neck,  the  small  size  of  the  trachea,  its  mobility  and  depth  and 
the  high  level  at  which  the  great  vessels  frequently  cross  it.  The  full 
length  of  the  cervical  portion  of  the  trachea  in  a  child  of  3  to  5  years 
is  about  1^  inches. 

The  cartilages  prevent  the  collapse  of  the  tube  from  internal  suction 
and  external  atmospheric  pressure  in  inspiration  and  the  pressure  of  en- 
larged thyroids  and  other  tumors.  Constant  pressure,  as  of  a  large 
goitre,  may  cause  the  gradual  absorption  of  the  rings  beneath  the  area  of 
pressure,  so  that  a  long,  special  form  of  tracheal  tube  may  be  required 
to  avoid  collapse  of  tiie  trachea.  Ossification  of  the  tracheal  cartilages 
commences  at  about  40  to  50  years  of  age.  In  the  child  the  trachea 
collapses  on  slight  pressure,  owing  to  the  yielding  character  of  the  thin 
cartilaginous  rings.  Treves  mentions  a  case  where  he  saw  the  trachea 
of  an  infant  bent  on  itself  and  invaginated  into  its  lumen  by  the  pil««t 
of  the  tracheotomy  tube. 

The  musculo-membranous  posterior  portion  of  the  tracheal  wall  is 
in  contact  iriflt  the  rrxophagus  which  deviates  somewhat  to  the  left  in 
the  lower  part  of  the  neck.     The  absence  of  cartilaginous  rings  be- 


138  THE  HEAD  AND  XECK. 

tween  the  trachea  and  oesophagus  avoids  the  pressure  of  the  trachea 
upon  the  oesophagus,  which  might  impede  deglutition.  Impacted  for- 
eign bodies  or  malignant  disease  in  the  oesophagus  may  cause  serious 
difficulty  is  respiration  by  pressure  on  the  posterior  soft  portion  of  the 
tracheal  wall.  These  two  tubes  adhere  together  by  loose  connective 
tissue,  allowing  movements  of  one  upon  the  other.  The  easily  felt  tra- 
chea is  of  great  importance  as  a  landmark  in  external  oesophagotomy 
in  the  neck.  In  the  angle  between  them  lie  the  recurrent  laryngeal 
nerves,  the  right  being  more  behind,  the  left  to  the  side  of  the  trachea. 
The  common  carotid  arteries,  and  the  other  contents  of  their  sheaths, 
as  well  as  the  inferior  thyroid  and  the  vertebral  arteries,  are  near 
enough  to  be  said  to  be  in  relation  with  the  trachea  on  the  sides  but  are 
not  near  enough  to  disturb  the  operator  in  tracheotomy,  especially  if 
he  keeps  strictly  in  the  median  line  and  is  careful  to  fix  the  trachea 
by  a  sharp  hook  in  that  line.  In  a  low  tracheotomy  the  great  vessels 
are  nearer  the  sides  of  the  trachea  than  they  are  above  where  the  lobes 
of  the  thyroid  gland  intervene. 

Foreign  bodies  in  the  trachea  are  usually  arrested  at  its  bifurcation 
and  if  they  pass  beyond  this  it  is  into  the  right  bronchus  as  a  rule  (see 
p.  223).  They  entail  a  fatal  result  unless  removed  by  coughing  or 
bv  operation.  Through  a  low  tracheotomy  they  can  sometimes  be 
reached  and  removed  by  a  long  forceps  as  low  down  as  the  bifurca- 
tion, but  more  often  they  are  expelled  by  a  violent  fit  of  coughing, 
through  the  wound  or  through  the  glottis,  at  the  time  of  operation  or 
subsequently. 

High  tracheotomy  is  not  infrequently  done  as  a  preliminary  operation 
in  several  operations  about  the  mouth  and  neck.  Its  object  is  usually 
to  prevent  blood  entering  the  trachea  and  for  this  purpose  the  trachea 
is  plugged  around  the  tube  by  one  of  the  several  tampon  cauulse  or  by 
small  pieces  of  sponge  or  gauze.  In  every  tracheotomy  a  slight  amount 
of  blood  enters  the  trachea  when  it  is  opened,  but  if  it  merely  comes 
from  a  venous  oozing  the  latter  soon  ceases  when  the  air  rushes  into 
the  lungs  and  the  right  heart  is  allowed  to  empty  itself. 

Tiie  real  surgical  limit  of  the  trachea  is  the  episternal  notch  ;  the 
thoracic  part  of  the  trachea  is  described  among  the  contents  of  the 
thorax  as  is  also  the  entire  oesophagus. 

The  Thyroid  Gland.  (Fig.  35.) — Its  lateral  lobes  extend  from  the 
fifth  or  sixth  tracheal  rings,  three  fourths  of  an  inch  above  the  sternum, 
up  to  the  middle  of  the  thyroid  cartilage.  Their  greatest  dimenswm 
are  normally  about  2  inches  in  length,  1^  inch  in  breadth  and  |  inch  in 
thickness.  "When  the  lobes  distinctly  exceed  these  measurements  they 
may  be  considered  to  he  enlarged.  They  may  be  temporarily  enlarged 
in  menstruation.  In  infancy  and  in  females  they  are  relatively  larger 
than  in  adults  and  in  males  respectively  and  the  right  lobe  is  also 
commonly  larger  than  the  left.  It  is  also  noticeable  that  thyroid 
enlargements  {goitre,  bronchocele)  are  more  common  in  females  and  on 
the  right  side.  The  size  of  the  gland  commonly  diminishes  in  late  life. 
The  isthmus  varies  from  one  fourth  to  three  fourth  inches  in  height 


RKLATIOyS  OF  THE   TJIYROIIJ   dLASD.  139 

and  lies  in  front  of  the  second,  third  and  fourth  tracheal  rings,  but  it 
may  extend  up  to  the  cricoid  and  sometimes  nearly  down  to  the  ster- 
num. In  infants  it  is  but  slio;htly  devel<){)cd,  wliich  is  of  advantage 
in  tractlieotomy.  From  its  upj)er  margin,  or  the  adjacent  margin  of  the 
left  lobe,  springs  the  pyramidal  lobe  when  present,  as  it  is  in  about 
four  fifths  of  all  cases  (Streckeisen).  This  represents  a  remnant  of 
the  thyroglossal  duct  which  in  the  fretus  extends  upward  from  the 
isthmus  behind  the  hyoid  bone  to  the  foramen  cwcum  on  the  tongue 
and  from  which  the  isthmus  is  developed.  This  duct  occasionally 
remains  open  and  from  it  are  developed  the  accessory  thyroids,  not 
infrequently  found  in  the  neighborhood  of  the  hyoid  bone.  Other 
accessory  portions  of  the  thyroid,  originating  as  separated  portions  of 
the  main  lobes,  may  occur  from  the  region  of  the  aortic  arch  to  the 
hyoid  bone.  These  may  be  the  origin  oi  "  accessory  goUres"  which 
cause  difficulty  in  diagnosis  and  removal,  as  they  are  likely  to  be  very 
movable,  slipping  readily  into  the  mediastinum.  Deeply  seated  car- 
cinoma of  the  neck  may  also  have  its  origin  in  them. 

The  relations  of  the  thyroid  are  of  great  importance  in  reference  to 
the  symptoms  of  its  enlargement  and  the  operation  of  excision  or  enu- 
cleation of  such  enlargements.  It  is  covered  in  front  by  the  sterno- 
hyoid, sternothyroid,  and  omohyoid  muscles  and  overlapped  by  the 
anterior  border  of  the  sternomastoid.  It  lies  beneath  the  superficial 
and  middle  layers  of  the  deep  cervical  fascia.  It  is  enclosed  by  a 
fibrous  capsule  from  whose  inner  and  posterior  parts  two  broad  bands, 
the  .sii.^pensory  lir/ainents,  are  continued  upward  and  attached  to  the  cri- 
coid cartilage.  It  is  this  attachment  which  is  divided  in  tracheotomy 
to  allow  the  downward  retraction  of  the  isthmus.  This  fibrous  capsule 
is  to  be  opened  in  excision  of  the  gland.  The  thyroid  is  moulded  to 
the  underlying  trachea  and  larynx  and  is  attached  to  them  by  fibrous 
tissue,  where  it  is  in  contact,  as  well  as  by  the  suspensory  ligament. 
Hence  it  moves  with  them  in  deglutition,  an  important  point  in  the  diag- 
nosis of  bronchocele  from  other  cervical  tumors. 

The  enlarged  thyroid  may  compress  the  trachea,  especially  if  the 
enlargement  is  rapidly  formed,  for  it  is  held  down  by  the  overlying 
muscles.  Hence  to  relieve  the  dyspnoea  the  division  of  these  muscles 
or  of  the  isthmus  has  been  practiced,  but  often  with  unsatisfactory 
results.  In  chronic  enlargement  the  pressure  may  cause  erosion  of  the 
tracheal  rings  and  collapse  of  the  trachea.  When  the  enlargement  is 
unilateral  the  mobile  trachea  may  escape  pressure  by  being  pushed  to 
the  opposite  side.  Those  tumors  cause  the  most  marked  pressure 
symptoms  which,  developed  from  the  lower  end  of  the  gland  or  from 
an  accessory  gland,  lie  between  the  trachea  and  the  sternum. 

The  thick  posterior  border  is  in  contact  with  the  carotid  sheath  and  is 
grooved  by  the  common  carotid  artery.  A  large  goitre  may  press  the 
great  vessels  outward,  it  may  cause  congestion  of  the  face  and  head 
by  pressure  on  the  internal  jugular  and,  by  adhering  to  the  latter,  it 
may  add  to  the  difficulties  of  excision.  On  account  of  its  contact  with 
the  carotid  the  enlarged  thyroid  may  receive  pulsation  from  it  and  if 


140  THE  HEAD  AXB  NECK. 

a  unilateral  thyroid  tumor  is  soft  and  vascular  the  resemblance  to 
aneurism  is  still  closer,  especially  when  a  thrill  or  l)ruit  is  produced, 
as  may  be  the  case.  The  pressure  on  the  carotid  and  internal  jugular 
may  disturb  the  cerebral  circulation.  The  thyroid  also  is  in  contact 
with  the  lower  part  of  the  pharynx  and  with  the  cesophagus,  especially 
on  the  left  side,  and  when  enlarged  may  cause  dysphagia. 

The  relation  to  the  recurrent  laryngeal  nerves  is  of  the  utmost  im- 
portance, as  pressure  on  them  may  lead  to  their  paralysis  and  the  re- 
sulting alteration  or  loss  of  voice,  and  they  are  also  in  danger  of  being 
injured  in  excision  of  the  thyroid.  The  left  recurrent  nerve  is  more 
exposed  to  pressure  for  it  lies  more  external  to  and  less  behind  the 
trachea.  The  recurrent  nerves  are  in  danger  of  being  injured  in  the 
ligation  of  the  inferior  thyroid  artery,  being  most  often  found  in  front 
of  or  behind  the  two  branches  of  this  artery,  near  the  point  of  bifur- 
cation. Hence  the  artery  is  tied  only  once,  carefully,  and  severed 
close  to  its  entrance  on  the  postero-inferior  aspect  of  the  gland.  The 
sympathetic  nerve  is  also  in  close  relation  to  the  trunk  of  this  artery, 
usuallv  embracing  it,  and  the  middle  cervical  ganglion  is  in  contact 
with  it.  As  the  gland  is  supplied  by  branches  from  this  ganglion  the 
latter  has  been  removed  for  the  cure  of  exophthalmic  goitre. 

Relatively  to  the  volume  of  the  gland  the  arteries,  superior,  inferior 
and,  when  present,  the  thyroidea  ima,  are  of  large  size,  so  that  the 
gland  is  one  of  the  most  vascular  of  organs.  There  is  but  little  arterial 
anastomosis  between  the  two  sides  along  the  isthmus,  but  a  branch  to 
the  pyramidal  lobe  from  the  superior  thyroid  may  cross  the  upper  end 
of  the  trachea  and  be  in  the  way  in  tracheotomy.  The /our  arteries 
are  situated  at  the  four  angles  or  poles  of  the  two  lobes  and  run  some 
little  distance  on  the  posterior  surface  before  entering  the  gland.  The 
inferior  thyroid  artery  passes  in  front  of  the  vertebral  and  behind  the 
common  carotid  a  little  below  the  transverse  process  of  the  sixth  cervical 
vertebra.  There  is  usually  a  venous  anastomosis  ]ust  above  and  below 
the  isthmus  ;  the  former  is  between  the  superior  veins,  the  latter  is  the 
starting  point  for  the  inferior  thyroid  veins.  The  superior  veins  cross 
the  external  or  common  carotid,  the  inferior  threaten  the  operator  on 
either  side  of  the  wound  in  a  low  tracheotomy.  The  middle  veins 
cross  the  common  carotid  about  where  the  omohyoid  crosses  it. 

The  function  of  the  gland,  still  imperfectly  understood,  concerns 
the  manufacture  of  the  blood  (especially  as  to  its  chemical  composi- 
tion), the  regulation  of  the  blood  supply  of  the  head  (especially  the 
brain)  and  the  control  of  mucinoid  substances.  It  also  has  important 
internal  secretory  propertie.^.  Its  atrophy,  destruction  or  complete  re- 
moval, or  the  degenerated  goitrous  condition  met  with  in  cretins,  is 
likely  to  lead  to  myxoedema,  a  condition  in  which  a  mucinoid  substance 
is  deposited  in  the  subcutaneous  tissues,  especially  in  the  eyelids,  lips 
and  hands.  Hence  the  entire  gland  should  never  be  removed  for  a 
simple  goitre.     Cretinism  is  also  associated  with  idiocy. 

The  most  important  pathological  changes  involving  the  thyroid  con- 
sist in  an  enlargement  of  a  part  or  the  whole  of  the  gland,  known  as 


PLATE   XI  I 


LEFT    BRACHIO- 
CEPHALIC   VEIN 


TO    VERTEBRAL 
COLUMN 


TO    PERICARDIUM 

Sagittal  section  of  the  cer-vical  fascia  between  the 
hyoid  and  sternum.     (Gerrish,  after  Testut. ) 


FIG.  37. 


Sagittal    section    of   the     cervical   fascia   in   the 
clavicular  region.     (Gerrish,  after  Testut.) 


PLATE   XIII. 


FIG.  38. 


ANTERIOR 


THYROID 


SUPERFICIAL   LAYER 

FORMING    SHEATH    OF 

STERNO-MASTOID 

RECURRENT 

LARYNGEAL- 

NERVE 

INT    JUGULAR         ^ 
VEIN '     ^ ' 
COMMON    CARO  _ 

TID    ARTERY     _^t 
VAGUS    NERVE 
SCALENUS   ANTI-    ^^ 
CUS    MUSCLE 


TRAPEZIUS 
MUSCLE 


OLE    LAYER 
FASCIA 
RECURRENT 
LARYNGEAL 
NERVE 

OMO-HYOID 
MUSCLE 
DEEP    LAYER 
OF    FASCIA 

\       PHRENIC 
■i  NERVE 

•S     \_SYMPATHETIC 
;    ll  NERVE 

f 


Transverse  section  of  the  neck  through  the  sixth  cer- 
vical vertebra,  to  show  the  layers  of  the  deep  cervical 
fascia  and  their  relations.  Lower  segment  of  the  sectioti. 
(Tillaux.) 


THE  DEEP  CERVICAL  FASCIA.  141 

(/oltre,  bronchocele  or  struma.  This  enlargement  may  iiiv<jlve  all  the 
elements  nearly  equally  or  either  the  parenchyma,  the  fibrous  or  vascu- 
lar elements  more  especially.  Thus  we  may  have  soft  parenchymatous 
goitres,  often  with  one  or  more  cysts  from  enlarged  vesicles,  hard 
fibrous  goitres  and  again  soft  vascular  goitres.  The  latter  are  associ- 
ated with  exophthalmos  and  tachycardia  in  exophthalmic  goitre.  The 
latter  form  may  be  due  to  an  abnormality  of  the  inhibitory  fillers  from 
the  middle  cervical  sympathetic  ganglion,  which  supply  the  vessels  of 
the  thyroid,  hence  this  ganglion  has  been  removed  to  cure  the  goitre. 
For  this  and  the  other  forms  of  goitre,  especially  when  they  cause  dis- 
turbance from  ])ressure,  excision,  enuclcatirir/  excision,  or  enucletdion  is 
done.  One  side  only  is  usually  operated  on  in  excision,  but  in  the 
latter  two  forms  of  operation,  where  part  of  the  gland  is  left,  both  sides 
may  be  dealt  with. 

In  Kochcr's  method  of  excision  the  incision  begins  over  the  sterno- 
mastoid  at  the  level  of  the  thyroid  cartilage,  runs  internally  in  the  line 
of  the  cutaneous  folds  to  the  median  line  and  then  follows  the  latter 
to  the  sternum.  A  flap  is  turned  back  c(ftcr  dividing  the  skin,  subcu- 
taneous tissue,  platysma,  anterior  jugular  vein,  a  branch  to  this  from 
the  facial  vein  along  the  anterior  border  of  the  sternomastoid  and  a 
transverse  anastomosis  between  the  two  anterior  jugulars  at  the  bottom 
of  the  neck.  After  dividing  the  superficial  and  middle  layers  of  the 
cervical  fascia  in  the  median  line  between  the  infrahyoid  muscles,  the 
sternohyoid  and  sternothyroid  muscles  are  partly,  or  wholly,  divided 
at  their  upper  ends.  The  capsule  of  the  gland  is  then  opened.  It  is 
the  veins,  often  distended  from  the  dyspnoea  which  the  jiatient  suffers, 
that  give  the  principal  trouble,  and  large  accessory  thin-walled  veins 
are  often  met  with  in  large  goitres.  When  the  veins  are  tied  and 
divided  so  as  to  get  beneath  the  tumor  its  superior  vessels  are  cut 
between  two  ligatures  at  the  upper  pole,  the  inferior  thyroid  artery 
cautiously  ligated  and  its  branches  cut  where  they  enter  the  gland,  the 
inferior  thyroid  veins  cut  between  two  ligatures,  the  gland  enucleated 
from  below  or  above  and  the  isthmus  divided  after  being  ligated. 
The  enncleaiinc/  excision,  in  which  the  inner  part  of  the  lobe  is  left, 
avoids  the  danger  of  injuring  the  recurrent  laryngeal  nerve  which  is 
sometimes  separated  from  the  gland  with  difficulty. 

The  deep  cervical  fascia  (Figs.  36,  37  and  38)  is  of  considerable 
surgical  importance  but  its  descrijition  differs  with  almost  every  writer 
on  the  subject,  owing  in  part  to  the  individual  differences  met  with  in 
almost  every  case.  In  general  three  layers  may  be  described  below  the 
hyoid  bone.  The  superficial  layer  s])lits  to  enclose  the  sternomastoid 
and  trapezius  muscles  in  a  sheath.  This  layer  on  the  two  sides  unites 
anteriorly  in  the  median  line  and  posteriorly  with  the  ligamentum 
nuchfc,  thus  forming  a  complete  investment  of  the  neck.  Below  it  is 
attached  to  the  sternum,  clavicle  and  the  acromion  and  spinous  proc- 
esses of  the  scapula.  In  the  anterior  media)}  line,  below  the  thyroid 
gland,  this  layer  sjt/its  into  two  tlirisions  attached  to  the  anterior  and 
posterior  border  of  the  episternal  notch.      P)e(we(Mi  these  two  divisions 


142  THE  HEAD  AND  NECK. 

is  a  triangular  space,  continuous  with  the  space  between  the  two  layers 
of  the  sheath  of  the  sternal  head  of  the  sternoraastoid,  and  containing 
cellular  and  adipose  tissue  and  one  or  two  small  lymph  nodes  (Paulet). 
Above  the  hifoid  bone  it  splits  to  form  a  sheatJt  for  the  mbinaxillarij  r/land 
which  is  attached  to  the  lower  border  of  the  jaw.  Above  this  it  is 
continuous  with  the  parotid  and  masseteric  fascia.  From  the  anterior 
border  of  the  sternomastoid  sheath  a  prolongation  passes  forward  to 
the  angle  of  the  jaw  which  separates  the  sheath  of  the  submaxillary 
from  that  of  the  parotid  gland  and  is  continued  to  the  styloid  process 
as  the  sfi/hma.villari/  Ugament. 

The  middle  layer  is  attached  to  the  hyoid  bone,  covers  the  muscles 
above  it  which  form  the  floor  of  the  submaxillary  triangle,  and  is 
attached  to  the  mylohyoid  ridge.  Below  the  hyoid  it  forms  a  sheath 
for  the  sternohyoid,  sternothyroid  and  omohyoid  muscles.  In  the 
median  line,  in  the  interval  between  these  muscles,  the  fascia  of  the 
two  sides  joins  together  and  with  the  superficial  layer,  forming  a  kind 
of  iinea  alba  of  the  neck  in  the  line  of  median  incision.  Laterally  this 
layer  is  said  by  some  to  reach  only  as  far  as  the  limit  of  the  omohyoid, 
which  it  ensheathes,  and  by  others  to  join  the  superficial  layer  at  or 
near  the  posterior  border  of  the  sternomastoid.  Inferiorly  it  is  at- 
tached to  the  posterior  border  of  the  episternal  notch  and  sends  an  ex- 
pansion around  the  left  brachiocephalic  vein,  which  is  continuous  with 
the  fibrous  layer  of  the  pericardium..  More  laterally  it  is  attached  to 
the  postero-superior  border  of  the  clavicle,  whence  it  sends  an  expan- 
sion around  the  great  veins  behind  it  (subclavian  and  internal  jugular). 
Thence  it  passes  to  the  sheath  of  the  subclavius  muscle  and  from  the 
latter  is  continuous  with  the  clavipectoral  fascia  (costocoracoid  mem- 
brane) and  the  sheath  of  the  axillary  vessels. 

From  the  deep  surface  of  this  layer  are  given  off  cellular  expansions 
which  surround  in  a  sheath-like  manner  the  trachea,  thyroid  body  and 
carotid  vessels  but  do  not  deserve  the  name  of  fascia,  although  some- 
times described  as  a  distinct  "tracheal  layer."  The  '^suspensory  liga- 
menf  of  the  thyroid  gland,  attaching  it  to  the  cricoid  cartilage,  is 
derived  from  this  expansion.  According  to  Merkel  the  carotid  slieath 
is  made  up  of  loose  connective  tissue  and  does  not  deserve  the  name  of 
sheath. 

The  deep  or  prevertebral  layer  covers  the  prevertebral  muscles  and  is 
attached  laterally  to  the  cervical  transverse  processes,  where  it  is  con- 
tinuous with  the  sheath  of  the  scalenus  anticus  muscle  and  of  the 
bracliial  ])lexus.  Thence  it  passes  outward  to  join  the  superficial  layer. 
Inferiorly  it  is  continuous  with  the  sheath  of  the  subclavian  and  axil- 
lary vessels.  According  to  some  it  completes  the  carotid  sheath  pos- 
teriorly.     It  lies  behind  the  oesophagus  and  pharynx. 

The  occipital,  superior  carotid  and  submaxillary  triangles  are  roofed 
over  by  the  superficial  layer  ;  the  subclavian  and  inferior  carotid 
triangles  by  the  superficial  and  middle  layers.  The  layers  as  thus 
described  bound  certain  spaces  and  the  great  practical  importance  of 
this   fascia   consists   in  its  tendency  to   limit  the  growth  of  cervical 


ABSCESS  BENEATH  THE  DEEP  CERVICAL  FASCIA.  l-t3 

tumors  and  the  course  of  cervical  abscesses.  This  limitation  is  by  no 
means  absolute,  for  abscesses  often  break  through  fascial  planes. 
Cold  abscesses  are  more  likely  to  be  guided  by  fascial  planes  than 
those  due  to  an  acute  inflammation. 

Beticeen  the  supcrjicial  fascia  and  the  superficial  layer  of  the  deep 
fascia  lies  the  external  jugular  vein,  the  platysrna  and  loose  tissue. 
Abscess  here  perforates  externally  and  so  does  one  between  the  super- 
ficial and  middle  layers,  as  the  superficial  layer  is  generally  thin  and 
offers  little  resistance  to  pus.  Abscess  between  the  superficial  and 
middle  layer  is  prevented  from  descending  into  the  mediastinum  and 
axilla  by  the  attachment  of  the  middle  layer  to  the  sternum  and 
clavicle.  Suppuration  is  more  common  here  than  elsewhere  in  the 
neck.  This  compartment  contains  the  anterior  jugular  veins,  loose 
connective  tissue  and  lymphatic  nodes. 

Abscess  in  the  third  compartment,  that  between  the  middle  and  deep 
layers,  can  not  reach  the  surface  without  perforating  the  two  overly- 
ing layers,  hence  unless  promptly  relieved  it  is  likely  to  e.vtend  down 
into  the  inediastimua  or  axilla,  with  which  this  space  is  continuous, 
depending  for  its  course  upon  whether  the  abscess  is  situated  mesially 
or  laterally.  Mesially  they  follow  the  loose  tissue  around  the  trachea 
and  oesophagus,  as  after  operations  on  the  base  of  the  tongue,  the 
larynx,  trachea,  thyroid  or  cesophagus.  As  this  compartment  also 
contains  the  most  important  structures  of  the  neck,  the  trachea,  oesoph- 
agus, thyroid  gland,  carotid  artery,  and  the  accompanying  vein, 
nerves  and  lymph  nodes,  an  abscess  may  exert  a  serious  pressure  upon 
these  structures.  For  these  two  reasons  an  early  incijiion  in  such  deep 
abscesses  of  the  neck  is  imperative.  Owing  to  the  lack  of  it  such 
abscesses  have  burst  into  the  trachea  or  cesophagus  and  even  into  the 
pleura.  Occasionally  they  have  opened  into  the  great  vessels  as  in 
a  remarkable  case  reported  by  Mr.  Sarony,  where  a  considerable  part 
of  the  common  carotid,  a  still  larger  part  of  the  internal  jugular  vein 
and  a  large  part  of  the  vagus  nerve  were  destroyed  (Treves).  Such 
cases  depend  upon  the  unyielding  character  of  the  cervical  fascia. 

In  the  fourth  coinpartiaent  an  abscess  is  known  as  prevertebral,  or 
retrop/iaryiif/eal,  if  above  the  lower  limit  of  the  pharynx.  The  latter 
form  may  be  opened  through  the  mouth  or  from  the  side  of  the  neck 
and  if  unrelieved  may  gravitate  down  into  the  mediastinum.  Later- 
ally these  deep  abscesses  may  follow  the  brachial  plexus  to  the  j)osterior 
triangle  or  even  to  the  axilla.  In  general  then  superficial  abscesses, 
or  those  external  to  the  middle  layer,  are  comparatively  safe,  showing 
a  tendency  to  perforate  and  open  externally  ;  deep  abscesses,  or  those 
beneath  the  middle  layer,  arc  dan(/crout<  from  pressure  or  the  liability  to 
extend  into  the  mediastinum  and  should  be  relieved  by  incision  as 
promptly  as  possible. 

As  the  cervical  fascia  gives  a  sheath  to  the  large  veins  that  perforate 
it  and  are  in  contact  with  it  and  attaciies  them  closely  to  the  adjacent 
bones  and  muscles  they  are  thereby  held  patent  and  ready  for  the  free 
flow  of  blood  from  the  head  and  neck  and  at  the  same  time  thev  are 


144  THE  HEAD  AND  XECK. 

liable  to  gape  when  wounded,  so  as  to  admit  air.  Hence  they  should 
always  be  ligated  before  division.  According  to  some  the  cervical  fascia, 
by  reason  of  its  firmness  and  its  attachment  to  bones  above  and  below, 
supports  the  soft  parts  of  the  neck  and  helps  them  to  resist  atmospheric 
pressure  in  inspiration,  as  first  pointed  out  by  Allan  Burns. 

The  lymphatic  nodes  (Fig.  89)  of  the  neck  receive  the  lymphatics 
of  the  head  ((nd  face  and  are  liable  to  become  enlarged  in  the  course  of 
the  various  septic,  tubercular,  syphilitic  and  cancerous  affections  of  the 
parts  from  which  their  lymphatics  come.  Among  enlarged  lymph  nodes 
of  the  neck  It/mphadenoma  of  tubercular  origin  is  a  very  common  condi- 
tion and  forms  the  majority  of  tumors  of  the  neck,  the  source  of  infection 
being  usually  the  upper  air  passages  (nose,  nasopharynx,  pharynx  and 
tonsils).  The  breaking  down  of  enlarged  cervical  nodes  is  a  common 
cause  of  abscess  of  the  neck.  It  follows  that  it  is  important  to  have 
a  clear  idea  of  the  sources  from  which  the  several  groups  of  nodes  are 
supplied  both  to  aid  in  the  diagnosis  of  the  primary  lesion  and  in 
order  to  know  where  to  look  for  lymphatic  involvement  in  any  given 
lesion. 

The  suboccipital  nodes,  just  below  the  posterior  attachment  of  the 
occipito-frontalis,  receive  lymph  from  the  back  part  of  the  scalp  and 
are  frequently  enlarged  in  secondary  syphilitic  eruptions  of  this  part. 
The  mastoid  nodes,  just  over  the  insertion  of  the  sternomastoid,  and 
the  parotid  nodes,  on  and  in  the  parotid  gland,  receive  the  lymph  from 
the  middle  and  anterior  part  of  the  scalp  respectively.  The  parotid 
nodes  also  receive  lymphatics  from  the  cheek,  outer  parts  of  the 
lids,  all  of  the  parts  within  the  cranium,  and  the  postpharyngeal 
nodes.  For  the  latter  as  a  focus  for  postpharyngeal  abscess  see  p. 
114.  The  submaxillary  nodes,  under  the  sheath  of  the  submaxillary 
gland  in  the  digastric  triangle,  form  a  chain  below  the  jaw.  Their 
tributaries  com  ^  from  the  salivary  glands,  lips,  floor  of  the  mouth,  fore 
part  of  the  tongue,  nose  and  frontal  region.  The  one  or  two  median 
suprahyoid  nodes,  on  the  mylohvoid  and  between  the  anterior  bellies 
of  the  digastric,  receive  lymphatics  from  the  middle  of  the  lower  lip 
and  the  chin.  The  deeper  internal  maxillary  group  at  the  sides  of  the 
fore  part  of  the  pharynx  receive  lymph  from  the  orbit,  the  palate, 
the  greater  part  of  the  nasal  cavity,  the  upper  jaw,  the  deep  surface 
of  the  cheek,  the  back  part  of  the  tongue  and  the  greater  part  of  the 
pharynx. 

The  above  nodes  empty  into  the  superficial  and  deep  cervical  groups. 
The  snperficial  cervical  nodes  (4—6)  lie  along  the  external  jugular  vein, 
between  the  platysma  and  deep  fascia,  and  receive  lymphatics  frora 
the  sulioccipital,  mastoid  and  submaxillary  nodes,  the  ear  and  the  sur- 
face of  the  neck.  Those  in  the  subclavian  triangle  communicate  with 
the  axillary  nodes  and  hence  may  be  enlarged  in  carcinoma  of  the 
breast.  On  account  of  their  communication  with  the  lym{)hatics  of 
the  ceso])hagus  the  enlargement  of  these  su])raclavicular  lymph  nodes 
in  cancer  of  the  stomach  is  regarded  l)v  Virchow  and  others  as  of 
diagnostic  value,  though  it  is  unusual.     The  deep  cervical  nodes  accom- 


PLATE   X  IV. 

Fro.  39. 


Connects  with 

Superior 

Mediaitinal  Nodes 


Connects  with 
Axillary  Nodes 


Diagram  of  the  lymph-nodes  and  vessels  of  the  head  and  neck, 
showing  the  regions  >A^hich  are  drained  into  each  group  of  nodes. 
Deep  structures  in  red,  superficial  in  black.     ( F.   H.  Gerrish.) 


EMBRYOLOGY  OF  TJIIC  NECK.  145 

puny  the  internal  jugular  vein  and  are  arranged  m  trro  seta,  Xha  upper 
about  and  above  the  bifurcation  of  the  carotid  and  the  lower  set  below. 
They  receive  all  the  lym])haties  of  the  head  and  neck  directly  or  indi- 
rectly by  receiving  the  lymphatics  from  the  superficial  set  and  those 
from  tiie  other  groups  which  do  not  em])ty  wholly  into  the  latter.  At 
the  base  of  the  neck  they  communicate  with  the  mediastinal,  subcla- 
vian and  axillary  nodes. 

Of  the  deep  set  the  nodes  near  the  bifurcation  of  the  carotid  often  first 
show  enlargement,  but  in  most  cases  where  the  nodes  are  exposed  by 
operation  many  more  are  involved  than  expected  and  a  chain  of  glands, 
gradually  decreasing  in  size,  leads  from  the  position  of  the  visible  tumor. 
Therefore  in  reniovincj  cervical  li/mphadenorna  the  operation  often  proves 
more  extensive  and  formidable  than  ex])ected.  They  may  be  con- 
siderably enlarged  without  detection  by  j)alpation  and  we  often  feel 
them  without  suspecting  their  real  size  or  numbers.  In  removing 
them  their  relation  to  the  internal  jugular  vein  is  of  great  importance, 
as  they  may  be  adherent  to  it  and  difficult  to  separate  from  it,  espe- 
cially when  involved  secondarily  to  cancer.  With  the  exception  of  a 
few,  like  the  superficial  cervical  group,  the  cervical  lymph  nodes  lie 
beneath  the  deep  fascia.  They  may  also  be  enlarged  in  the  rare  cases 
of  lymphoi^arcoma,  and  the  peculiar  affection  known  as  Ho(lgkin\'i  dis- 
ease. Although  in  most  cases  of  involvement  of  the  lymph  nodes  the 
infection  comes  from  the  same  side  of  the  body  as  the  enlargement,  yet 
in  exceptional  cases  it  comes  from  the  opposite  side.  Thus  exception- 
ally when  one  side  of  the  tongue  is  the  seat  of  epithelioma  the  opposite 
submaxillary  nodes  are  involved. 

Embryologically  the  neck  is  formed  by  the  coalescence  of  five 
visceral  or  branchial  arches  separated  by  four  furrows  or  branchial  clefts. 
These  clefts,  seen  on  the  surface,  correspond  to  a  like  number  of  inner 
clefts  or  pharyngeal  pouches  on  the  walls  of  the  pharynx,  separated 
from  the  outer  clefts  by  a  thin  chiding  niemhrane,  composed  of  a  layer 
of  entoderm  and  one  of  ectoderm.  Of  these  arches  and  clefts  the  first 
arch  forms  the  lower  and  upper  jaws,  the  incus  and  the  malleus ;  the 
second  the  stapes,  the  styloid  process,  the  stylohyoid  ligament  and  the 
lesser  corn u  of  the  hyoid  bone;  the  third  forms  the  body  and  great 
cornu  of  the  hyoid  ;  the  fourth  and  fifth  form  no  special  structures. 
The  first  outer  cleft  forms  the  external  ear,  the  corresponding  inner  cleft 
the  middle  ear  and  Eustachian  tube  and  the  closing  membrane  between 
them  forms  the  membrana  tympani.  The  fourth  inner  cleft  forms  the 
lateral  lobes  of  the  thyroid  gland  and  the  tissues  adjacent  to  the  second 
cleft  take  jxirt  in  forming  the  posterior  third  of  the  tongue  and  the 
middle  portion  (isthmus)  of  the  thyroid  gland. 

If  the  lower  branchial  arches  do  not  fuse  together,  as  they  normally 
should  in  the  second  month  of  fa>tal  life,  the  corres])onding  cleft 
remains  partly  open  as  a  so-called  branchial  fistula.  These  may  be 
lateral  or  median  in  position  and  complete  or  incomplete.  In  the  case 
of  complete  fi.stukr  the  closing  membrane  gives  way  and  there  is  a 
narrow  canal  lined  by  mucous  membrane,  leading  from  without  back- 
10 


146  THE  HEAD  AND  NECK. 

ward,  inward  and  upward  for  1^  to  2|  inches.  The  internal  opening 
of  such  a  fistula  is  in  the  lower  part  of  the  pharynx  or  in  the  posterior 
palatine  arch  near  the  tonsil.  The  external  opening  varies  in  position 
according  to  the  cleft  which  remains  open,  being  most  often  near  the 
sternoclavicular  joint,  in  the  region  of  the  fourth  cleft,  or  at  the  an- 
terior or  posterior  border  of  the  sternomastoid  near  the  larynx,  in  the 
second  or  third  cleft.  Incomplete  Jistulce  open  either  externally  or 
internally  in  the  same  position  as  one  end  of  a  complete  fistula.  Near 
the  external  opening  of  a  fistula,  or  in  spots  where  they  commonly 
open,  a  protruding  fold  of  skin  may  be  found  and  above  it  a  cartilag- 
inous mass  is  sometimes  to  be  felt.  As  the  external  ear  is  formed  by 
the  fusion  of  six  similar  nodules  at  the  outer  end  of  the  first  visceral 
cleft,  the  more  prominent  of  these  are  called  supernumerary  auricles. 
Median  fistulse  of  the  neck,  or  tracheal  fistulae,  are  rare  and  if  incom- 
plete and  internal  may  give  rise  to  air  tumors.  Congenital  dicerticula 
of  the  (esophagus  are  probably  always  incomplete  lateral  branchial 
fistulte  of  the  neck. 

From  obstruction  of  the  external  or  internal  opening  of  a  fistula  or 
from  a  portion  of  the  wall  of  the  cleft  shut  in  by  the  closure  of  the 
arches,  dermoid  and  branchiogenic  cysts  may  be  formed.  Such  shut-in 
portions  of  the  epithelial  tissue  may  be  the  nucleus  of  the  rare  primary 
carcinomas  of  the  neck. 


CHAPTER    11. 

THE   UPPER  EXTREMITY. 

The  upper  extremity,  the  organ  of  prehension  and  touch,  is  notable 
for  its  rnobiUty,  which  is  due  to  the  freedom  of  movement  of  its  joints 
and  its  many  muscles.  Its  only  bony  connection  Avith  the  skeleton  of 
the  trunk  is  through  the  clayicle. 

In  the  upright  position  the  upper  extremity  reaches  to  the  middle 
of  the  thigh,  the  right  being  stronger  and  ^-1  cm.  longer  as  a  rule. 
The  greater  deyelopment  of  the  right  upper  extremity  depends,  accord- 
ing to  Hyrtl,  on  the  arrangement  of  the  blood  supply  which  is  more 
abundant  and  comes  more  directly  from  the  heart  on  the  right  side. 
The  anomalous  origin  of  the  right  subclayian  as  the  last  branch  of 
the  aortic  arch  is  associated,  according  to  the  same  author,  with  left- 
handeduess  and  the  greater  development  of  that  side. 

THE  REGION  OF  THE  SHOULDER. 

This  comprises  the  upper  part  of  the  extremity  and  reaches  down 
to  the  insertion  of  the  pectoralis  major  and  latissimus  dorsi  muscles. 

Surface  Landmarks  and  Markings. — The  clavicle,  acromion  proc- 
ess and  spine  of  the  scapula  can  be  readily /tV^  suhcutaneousli/.  The 
clavicle  is  not  quite  horizontal,  but  inclines  slightly  upward  at  its  outer 
end  in  the  erect  position  and  even  more  so  in  the  reclining  position 
when  the  weight  of  the  arm  no  longer  pulls  it  down.  The  upper  sur- 
face is  only  covered  by  skin  and  platysma  and  the  anterior  and  pos- 
terior surfaces  are  more  or  less  readily  palpable.  The  deltoid  tubercle 
of  this  bone  may  be  felt  if  large  and  may  even  be  mistaken  for  an 
exostosis.  The  sternal  end  is  large  and  prominent  especially  in  mus- 
cular subjects  and  the  outer  or  acromial  end  is  often  enlarged  and 
projects  above  the  level  of  the  acromion  so  that  it  should  not  be  mis- 
taken for  a  dislocation  at  the  acromioclavicular  joint.  The  latter 
joint  is  in  the  vertical  line  passing  up  the  middle  of  the  arm  anteriorly. 
The  angular  prominence  which  can  be  felt  externally  at  the  junction 
of  the  acromion  and  tiie  sj)ine  of  the  scapula  is  the  best  point  from  which 
to  measure  the  arm  down  to  the  external  condyle.  Tlie  latter  point, 
the  tip  of  the  acromion  and  the  radial  styloid  process  are  all  in  the 
same  line  when  the  arm  hangs  at  the  side  and  the  palm  looks 
forward. 

A\  hen  tile  arm  hangs  at  the  side  the  upper  angle  of  the  scapula  corre- 
sponds to  the  upper  border  of  the  second  rib,  the  lower  angle  to  the 
seventh  intercostal  space  and  the  vertebral  end  o(  the  spine  of  the  scapida 
to  the  third  intercostal  space,  to  the  interval   between  the  third  and 

147 


148  THE   UPPER  EXTREMITY. 

fourth  thoracic  spines  and  to  the  fissure  between  the  upper  and  lower 
lobes  of  the  lung. 

The  vertebralborder  of  the  scapula  may  be  made  prominent  by  carry- 
ing the  hand  as  far  as  possible  over  the  opposite  shoulder,  the  axillary 
border  and  inferior  angle  by  placing  the  forearm  behind  the  back. 

The  prominence  of  the  slioidder  is  due  to  the  acromion  process,  but 
the  roundness  ]\M^i  below  this  depends  upon  the  prominent  great  tu- 
berosity of  the  humerus  covered  by  the  deltoid  muscle.  Hence  this 
roimdness  gives  way  to  a  flattening  when  the  underlying  bony  bolster 
is  removed,  as  in  a  dislocation  of  the  shoulder,  or  is  diminished  in  bulk, 
as  in  an  impacted  fracture  of  the  anatomical  neck.  The  head  of  the 
humerus  can  be  felt  high  up  in  the  axilla,  especially  when  the  arm  is 
abducted,  which  brings  the  head  in  contact  with  the  loM'er  part  of  the 
joint  capsule.  The  lower  margin  of  the  glenoid  cavity  can  also  be  felt 
high  up  in  the  axilla  below  and  internal  to  the  humeral  head.  The 
head  and  internal  condyle  of  the  humerus  and  the  styloid  process  of  the 
ulna  are  in  the  same  line.  This  relation  of  the  head  and  internal  con- 
dyle, beingconstant  in  all  positions  of  the  arm,  is  of  value  in  the  diag- 
nosis of  injuries  about  the  shoulder  and  in  reducing  dislocations.  In 
thin  subjects  the  two  tuberosities  of  the  humerus  and  the  bicipital 
groove  between  them  can  be  felt  beneath  the  deltoid,  especially  on 
rotating  the  humerus.  The  bicipital  groove  looks  directly  forward 
when  the  arm  hangs  at  the  side  with  the  palm  of  the  hand  looking 
forward. 

The  groove  between  the  deltoid  and  pectoralis  major,  distinguish- 
able in  most  cases,  contains  the  cephaUc  vein  and,  more  deeply,  the 
humeral  branch  of  the  acromiothoracic  artery.  The  upper  end  of 
this  groove  widens  out  into  a  triangular  infraclavicidar  fossa,  the  base 
of  the  triangle  being  formed  by  the  clavicle.  On  deep  pressure  here 
the  Goracoid  process  can  be  felt  just  beneath  the  margin  of  the  deltoid 
and  a  little  below  the  clavicle.  The  depression  of  the  infraclavicular 
fossa  is  obliterated  in  suljcoracoid  dislocations  of  the  humerus,  in  some 
fractures  of  the  clavicle  with  displacement,  in  some  axillary  tumors, 
in  lymphatic  enlargements  and  in  inflammations  along  the  upper  part 
of  the  axillary  artery.  It  is  re])laced  by  a  prominence  in  intracoracoid 
dislocations  of  the  humerus.  If  the  muscles  are  relaxed  we  may  detect 
the  pulsation  of  the  axillary  artery  by  pressure  in  the  infraclavicular 
fossa  below  the  middle  of  the  clavicle  and  we  may  also  compress  the 
artery  against  the  second  rib.  By  a  vertical  incision  through  the  center 
of  the  coracoacroniial  ligament  the  shoulder  joint  is  opened  and  the 
biceps  tendon  is  encountered.  Hence  in  resection  of  the  shoulder 
joint  the  coracoid  process  is  a  landmark  for  the  incision. 

The  anterior  border  of  the  axilla  is  formed  by  the  lower  margin  of 
the  great  pectoral  muscle  which  passes  from  the  sixth  costal  cartilage  to 
the  outer  bicipital  ridge  and  nearly  follows  the  line  of  the  fifth  rib. 
The  anterior  and  posterior  axillary  borders  are  well  marked,  especially 
when  the  arm  is  abducted  to  an  angle  of  about  45°  and  the  muscles  form- 
ing these  borders  arc  contracted,  in  which  position  the  depression  of  the 


FRACTURE  OF  THE  CLAVICLE.  149 

axilla  is  deepest.  As  the  arm  is  raised  to  and  above  the  horizontal 
line  the  axillary  depression  becomes  shallower  by  reason  of  the  pro- 
jection into  it  of  tha  humeral  head,  the  approximation  of  the  anterior 
and  pi^sterior  axiUary  folds  and  tlie  projection  of  the  coracobrachial  is 
muscle  along  the  hnnioral  side  of  the  axilhi.  Wlicn  the  arm  is  brought 
nearly  to  the  side  the  thoracic  wall  bounding  the  axilla  internally  can 
be  explored  as  high  up  as  the  third  rib.  The  axillary  lymph  nodes  on 
this  or  on  the  outer  side  cannot  be  felt  unless  they  are  enlarged. 

Topography  of  Some  of  the  Deeper  Parts. — When  the  arm  is 
abducted  the  course  of  the  axillary  artery  is  represented  by  a  line  from 
the  ceuter  of  the  clavicle  to  the  groove  along  the  inner  border  of  the 
coracohrachialis  muscle.  The  latter  muscle  comes  well  into  view  when 
the  huuierus  is  rotated  a  little  outward. 

The  position  of  the  pectordli.i  ininor  muscle  is  outlined,  by  two  lines, 
converging  from  the  upper  border  of  the  third  and  the  lower  border 
of  the  fifth  rib,  just  external  to  their  cartilages,  to  the  coracoid  proc- 
ess. The  position  of  the  acromiothoracic  artery  is  indicated  by  the 
point  Avhere  the  upper  line  crosses  the  course  of  the  axillary  artery  and 
the  long  thoracic  (irtcry  runs  in  the  lower  line.  When  the  arm  hangs 
at  the  side  the  circumflex  nerve  and  posterior  circumflex  artery  wind 
around  the  humerus  under  the  deltoid  about  a  finger's  breadth  above 
the  center  of  the  vertical  axis  of  the  latter.  A  finger's  breadth  below 
this  point  the  dorsalis  scapulas  artery  crosses  the  axillary  border  of  the 
scapula. 

For  convenience  of  study  we  may  divide  the  shoulder  into  four 
regions.  (1)  The  anterior  or  clavicular  region  ;  (2)  the  posterior  or 
scapular  region  ;  (3)  the  outer  or  deltoid  region  (including  the  shoulder 
joint) ;  (4)  the  axilla. 

1.    The  Anterior  Region  of  the  Shoulder. 

This  is  also  called  the  clavicular  region  because  the  clavicle  forms  its 
bony  framework.  The  skin  over  this  region  is  loosely  attached  and 
hence  freely  movable,  a  fact  which  explains  why  it  usually  escapes  being 
wounded  in  contusions  and  which  partly  accounts  for  the  rare  occur- 
rence of  penetration  in  fractures  of  the  clavicle.  It  must  also  be  care- 
fully put  on  the  stretch  in  tlie  incision  for  subclavicular  ligation  of  the 
axillary  artery.  The  supraclavicular  nerves,  the  cutaneous  nerves  of 
this  region,  in  their  passage  in  front  of  the  middle  third  of  the  clavicle 
are  liable  to  contusion,  and  such  an  injury  explains  the  occasional 
severe  i)aiu  after  blows  on  the  clavicle.  According  to  Tillaux  the 
severe  pain  which  occasionally  persists  after  fractures  of  the  clavicle  is 
due  to  the  involvement  of  these  nerves  in  the  callus. 

Fracture  of  the  clavicle  is  one  of  the  commonest  forms  of 
fractures,  a  lact  diw  to  its  su[)erfic'ial  position,  its  slender  form  and  the 
circumstance  that  it  receives  a  large  share  of  almost  all  shocks  which 
involve  the  upper  extremity.  Such  fractures  are  more  often  due  to 
indirect  than   to  direct  violence.     Among   the  indirect  fractures  the 


150  THE    UPPER  EXTREMITY. 

great  majority  are  at  the  outer  end  of  the  middle  third  (i.  e.,  the  middle 
two  inches)  of  the  bone,  for  the  reason  that  this  is  the  most  slender 
and  most  sharply  curved  part  and  also  the  meeting  point  of  the  two 
curves  and  of  the  more  fixed  outer  third  with  the  more  movable  inner 
two  thirds.  In  this  connection  it  may  be  noted  that  the  clavicle  breaks 
in  such  cases  by  the  exaggeration  of  its  normal  curves. 

The  direction  of  the  fracture  is  accordingly  usually  obliquely  inward, 
downward  and  backward.  As  to  the  displacement  that  occurs  it  should 
be  borne  in  mind  that  the  clavicle  serves  as  a  kind  of  outrigger  to 
hold  the  shoulder  and  upper  extremity  away  from  the  thorax.  When 
this  support  is  broken  the  shoulder  with  the  outer  fragment  is 
naturally  displaced  inward  and  sinks  downward  by  its  own  weight. 
The  inward  displacement  also  causes  the  shoulder  to  8wing  forward  so 
that  the  common  displacement  of  the  inner  end  of  the  outer  fragment 
is  downward ,  inward  and  forward.  The  outer  end  of  the  outer  frag- 
ment is  also  rotated  forwards.  This  outrigger  action  of  the  clavicle 
may  be  illustrated  by  a  bar  supporting  a  sign  from  a  building,  the 
outer  end  of  the  bar  being  also  supported  by  a  chain  from  a  point 
higher  up  on  the  wall,  the  chain  representing  the  trapezius,  etc.  If  the 
bar  breaks  the  outer  end  with  the  sign  falls  downwards  and  inwards. 
But  this  is  not  the  only  and  perhaps  not  the  most  important  cause  of 
the  displacement,  the  other  causes  being  the  continuance  of  the  force  pro- 
ducing the  fracture,  the  direction  of  the  fracture  and  the  action  of  the 
muscles.  Thus  in  transv'erse  fractures  there  may  be  no  such  displace- 
ment, but  instead  of  it  an  upward  angle,  due  to  the  sinking  of  the 
shoulder,  or  no  displacement  at  all,  especially  in  green-stick  fractures. 
Again  if  the  oblique  direction  is  much  inclined  backward  the  inner 
end  of  the  outer  fragment  may  be  forced  behind  or  simply  below  the 
inner  fragment  and  not  in  front  of  it.  Among  the  muscles  the 
pectorals  and  latissimus  dorsi  pull  the  outer  fragment  inward  and 
downward.  The  outer  end  of  the  outer  fragment  is  rotated  forward 
by  the  pectorals  and  the  serratus  magnus.  The  inner  fragment,  if  dis- 
placed at  all,  is  pushed  up  by  the  outer  fragment  beneath  it,  rather 
than  pulled  up  by  the  sternomastoid. 

Owing  to  the  inward  displacement  of  the  outer  fragment  causing 
the  fragments  to  overlap,  there  is  necessarily  a  considerable  shortening 
which  may  nearly  equal  in  extreme  cases  one  third  the  length  of  the 
bone,  or  two  inches.  As  this  shortening  is  difficult  to  remedy  com- 
pletely it  follows  that  some  shortening  remains  permanently  after 
fracture  of  the  clavicle  more  often  than  after  any  other  fracture  save 
that  of  the  femur.  Tiiis  shortening  causes  some  narrowing  and 
rounding  of  the  affected  shoulder. 

It  follows  from  the  nature  of  the  displacement  that  reduction  is  to 
be  obtained  and  maintained  by  carrying  the  shoulder  upward,  outward 
and  backward.  Upward  pressure  on  the  elbow  carries  the  shoulder 
upward  and,  with  a  pad  in  the  axilla  as  a  fulcrum  and  the  arm  as 
a  lever,  inward  pressure  at  the  elbow  forces  the  shoulder  outward. 
Some  shortening  and  deforinifi/  usually  persists  and  any  forward  dis- 


COMPLICATIONS  OF  FRACTURE  OF  THE  CLAVICLE.  1'">1 

placement  of  the  outer  fragment  may  be  particularly  hard  to  keep 
reduced  unless  the  patient  is  willing  to  lie  perfectly  flat  on  the  back 
for  three  weeks  or  so.  In  this  rcriiriihent  posifion  the  weight  of  the 
arm  no  longer  drags  the  shoulder  downward  and  the  weight  of  the 
shoulder  and  the  pressure  of  the  body  on  the  scapula,  forcing  its  outer 
border  outward  and  backward,  pull  the  outer  fragment  outward  and 
backward  better  than  any  form  of  bandage.  The  mobility  of  the 
clavicle  and  the  number  of  strong  muscles  attached  to  it  explain  the 
difficulty  of  applying  a  satisfactory  fixed  dressing  and  the  tendency  of 
the  callus  to  become  excessive.  In  fraeture  of  the  outer  third,  which 
is  more  often  transverse  than  oblique,  there  may  be  no  ilisjj/dci'menf  or 
an  angular  one  due  to  the  forward  and  inward  turning  of  the  outer 
fragment. 

The  clavicle  may  be  broken  by  muscular  violence,  probably  by  the 
clavicular  fibers  of  the  pedoralix  major  and  dcUo'uJ.  These  tend  to 
draw  the  clavicle  dowuM'ard  and  forward,  in  which  position  the  outer 
fragment  is  displaced  in  such  cases.  These  fractures  are  most  often  in 
the  middle  third.  Violent  movements  of  the  limb  forward  and  inward 
or  upward  appear  to  be  the  commonest  cause.  Occasionally  the  frac- 
ture is  due  to  a  sudden  depression  of  the  arm  by  which  the  clavicle  is 
bent  over  the  first  rib.  Fractures  by  direct  violence  are  most  apt  to 
be  transve)^se  and  may  occur  at  any  point,  but  most  frequently  at  the 
middle  or  outer  third. 

Green-stick  fracture,  or  fracture  without  rupture  of  the  periosteum 
and  hence  without  much  displacement,  occurs  more  often  in  the  clavicle 
than  in  any  other  bone.  This  is  partly  due  to  the  fact  that  such  frac- 
tures occur  in  childhood  and  more  than  half  the  fractures  of  the  clavicle 
are  said  to  occur  before  the  age  of  five.  According  to  Kronlcin  frac- 
ture of  the  clavicle  in  children  takes  the  place  of  dislocation  of  the 
shoulder  by  direct  violence  later  in  life.  The  periosteum  at  this 
age  is  also  very  thick  and  loosely  cdtached.  Notwithstanding  the 
absence  of  deformity,  and  the  failure  of  diagnosis  that  may  result, 
the  callus  is  often  excessive,  owing  to  the  stripping  up  of  the  ac- 
tive periosteum. 

T\\e  firmness  of  the  periosteum,  l)ut  es])ecially  the  presence  beneath 
the  clavicle  of  the  suhclavius  uiuscle  enveloped  in  a  dense  fascia,  are 
largely  accountable  for  the  rare  oceurrence  of  the  complications  of  frac- 
tures of  the  clavicle,  which  consist  of  injuries  to  the  vessels,  nerves  and 
lung.  xUthough  the  vessels  and  nerves  lie  beneath  the  clavicle  in  the 
angular  interval  between  it  and  the  first  rib  in  the  following  order 
from  within  out,  subclavian  vein,  artery  and  brachial  plexus,  injuri/ 
to  the  arteri/\s  not  recorded,  unless  of  such  a  nature  as  to  produce  sub- 
sequent aneurism,  and  only  a  few  cases  of  injury  to  the  vein  and  brachial 
plexus  arc  on  record.  The  vein  from  its  position,  as  the  most  internal 
of  these  structures  in  the  acute  angle  between  the  clavicle  and  the  first 
rib,  and  from  its  slighter  resistance  is  likely  to  be  the  first  to  be  com- 
pressed. Injury  to  the  infertud  jur/ular  vein,  lying  behind  the  clavicle, 
has  also  been  recorded.     I  have  recently  seen  a  case  of  paralysis  of 


152  THE    UPPER   EX'I REMIT Y. 

the  arm  following  a  fall  on  the  shoulder  where  the  brachial  plexus  was 
found  reduced  to  a  mass  of  connective  tissue,  apparently  from  com- 
pression by  the  clavicle,  though  no  fracture  of  the  clavicle  resulted. 
Injury  to  the  lung  by  a  fragment  of  the  clavicle,  as  evidenced  by 
emphyseina,  has  been  observed  in  a  few  cases  and  in  other  cases  the 
emphysema  was  apparently  due  to  a  wound  of  the  soft  parts. 

The  interposed  pad  of  the  suhclarius  muscle  is  of  great  service  in 
resection  of  the  clavicle,  rendering  the  operation  easy  in  the  outer  two 
thirds  while  behind  the  sternal  third  are  the  innominate  or  left  carotid 
artery,  the  brachiocephalic  and  internal  jugular  veins,  the  vagus,  re- 
current and  phrenic  nerves,  the  thoracic  duct  and  the  trachea.  A  little 
more  externaUy  the  external  jugular  vein,  the  suprascapular  vessels  and 
the  apex  of  the  lung  lie  behind  the  clavicle.  In  case  of  enlargement  of 
the  clavicle  the  resection  of  its  inner  third  may  be  a  matter  of  consid- 
erable difficulty,  though  in  case  of  necrosis  with  thickening  of  the  peri- 
osteum the  operation  may  be  extremely  easy.  In  any  excision  of  the 
clavicle  the  operation  is  rendered  much  easier  and  safer  if  it  can  be 
done  subpcriosteally.  The  restoration  of  the  clavicle  after  subperiosteal 
resection  is  sometimes  very  complete,  but  even  when  no  new  bone  forms 
the  removal  of  the  entire  clavicle  is  followed  by  far  less  alteration  in 
position  and  impairment  of  motion  of  the  shoulder  than  would  be  ex- 
pected from  its  function  as  a  support  and  outrigger  for  the  shoulder. 
So  striking  is  this  in  some  cases  as  to  lead  one  to  question  whether  the 
displacement  in  fracture  of  the  clavicle  is  not  mostly  due  to  the  other 
factors,  /.  e.,  continuation  of  the  force  producing  the  fracture,  muscular 
action,  and  the  direction  of  the  fracture. 

Avulsion  of  the  entire  upper  extremity  has  occurred  in  a  number  of 
cases,  especially  in  machine  accidents.  Apart  from  the  sternoclavic- 
ular articulation  only  muscles  hold  the  upper  extremity  to  the  trunk 
and  if  the  clavicle  is  fractured  only  the  rupture  of  muscles,  vessels  and 
nerves  is  necessary  in  avulsion. 

The  Sternoclavicular  Joint. — The  lack  of  adaptability  between 
the  bony  surfaces  forming  this  joint  accounts  largely  for  the  amount  of 
motion  that  occurs  here.  When  the  arm  hangs  at  the  side  the  clavicle 
is  in  contact  with  the  socket  only  at  its  lower  angle,  rendering  the 
cavity  V-shaped.  This  allows  the  elevation  of  the  shoulder  in  which 
position  the  bones  are  in  more  immediate  contact.  Accordingly  in 
disease  of  this  joint  the  motion  of  elevation  of  the  shoulder  is  that 
which  produces  the  most  ])ain. 

Dislocation  of  the  clavicle  from  the  sternum  is  rare  on  account  of  the 
strength  of  the  ligaments  that  bind  them  together.  It  may  be  com- 
plete or  incomplete  and  occurs  in  the  (1)  forward,  (2)  backward  and 
(3)  upward  direction,  in  the  order  of  frequency.  The  relative  fre- 
quency of  these  three  varieties  depends  upon  the  relative  strength  of 
the  ligaments  that  resist  them  and  that  restrict  the  movements  of  tlie 
joint.  Thus  dislocation  forward  is  resisted  by  the  posterior  and  an- 
terior ligaments  and  the  weakness  of  the  latter  serves  partly  to  explain 
the  relative  frequency  of  the  forward  dislocation.     The  head  of  the 


thp:  sternoclavicular  joist.  153 

bone,  (Vixplacexl  forward  and  usually  inward  and  downward,  rests  on 
the  niamtl)riuin  and  carries  with  it  the  sternomastoid  musele. 

Dislocation  backward  is  rcsisfrd  by  the  same  ligaments  and  in  addi- 
tion the  strong  rhomboid  ligament.  It  may  be  due  to  direct  or  indirect 
violence,  more  often  the  latter,  the  force  pressing  the  shoulder  forward 
and  inward.  The  Jiead  of  the  bone,  li/inf/  Ijeliind  the  sternum  and 
probably  between  it  and  the  sternothyroid  muscle,  frequently  jjre.sses 
upon  the  trachea  causing  dysi)no?a,  less  often  upon  the  cesophagus 
causing  dysphagia.  In  the  region  occupied  by  the  displaced  head  of 
the  bone  are  most  important  vessels  and  nerves,  but  the  cases  recorded 
show  no  serious  pressure  upon  them.  The  head  of  the  bone  has  been 
excised  in  one  case  to  relieve  troublesome  dysphagia.  In  complete  dis- 
locations either  forward  or  backward  the  head  of  the  clavicle  is  usually 
also  displaced  downward  and  in  all  complete  dislocations  it  is  as  a  rule 
displaced  inward  also. 

In  addition  to  the  ligaments  resisting  backward  dislocation,  dis- 
location upward  is  resisted  by  the  interclavicular  ligament  and  the  inter- 
articular  cartilage ;  hence  the  rarity  of  this  form,  which  implies  a 
tearing  of  all  the  ligaments.  It  is  usually  c/»e  to  forcible  depression  of 
the  shoulder,  the  first  rib  acting  as  a  fulcrum  so  that  the  inner  portion 
of  the  clavicle  is  elevated.  The  violence  continuing  forces  the  head 
inward  and  upward  behind  the  sternal  portion  of  the  sternomastoid. 
The  lack  of  adaj)tability  of  the  joint  surfaces  serves  to  explain  the 
ease  of  reduction  and  the  difficidtif  of  retention  in  most  cases  of  luxation 
in  this  joint.  The  recumbent  position  and  various  forms  of  dressing 
which  act  on  the  clavicle  through  the  shoulder,  as  in  fracture  of  the 
clavicle,  have  been  employed.  In  connection  with  these  the  injection 
of  50  per  cent,  alcohol,  or  a  similar  fluid,  with  the  object  of  producing 
a  mass  of  connective  tissue  around  the  joint  as  a  sort  of  new  capsule, 
has  occasionally  been  found  useful. 

The  sternoclavicukir  joint  is  liable  to  the  ordinary  diseases  of  joints 
and,  according  to  some,  is  more  often  involved  in  pysemia  than  other 
joints.  As  the  synovial  sac  is  divided  into  two  by  the  interarticular 
cartilage,  disease  may  commence  in  and  be  limited  to  one  sac,  but  as  a 
rule  the  entire  joint  (both  sacs)  become  involved.  Owing  to  the  fact 
that  the  anterior  sternocfavicidar  ligainent  is  the  thinnest  and  iceakest 
pjart  of  the  capsule  swellinr/  is  as  a  rule  first  evident  in  front  and,  when 
spontaneous  perj'oration  occurs,  the  pus  usually  escapes  anteriorly.  If, 
as  may  happen,  it  escapes  through  the  posterior  ligament  it  may  readily 
reach  the  mediastinum.  The  notable  fact  that  the  disease  of  this  joint 
never  results  in  anchylosis  is  due  chiefly  to  the  entire  lack  of  adapta- 
bility of  the  two  bony  surfaces  and,  to  a  less  extent,  to  the  constant 
slight  movement  here  and  the  occasional  persistence  of  the  interartic- 
ular cartilage.  The  importance  of  bearing  in  mind  the  r(7rt//o».s' of  this 
joint  to  the  great  vessels  behind  it  is  illustrated  by  a  case  reported  by 
Hilton  in  which  a  large  abscess  in  the  joint  received  pulsation  from 
the  subjacent  subclavian  or  innominate  artery  and  was  first  thought  to 
be  an  aneurism. 


154  THE    UPPER  EXTREMITY. 

The  acromioclavicular  joint  depends  for  its  strength  iipou  its 
lic/aiiients,  for  its  shallow  flat  joint  surfaces  are  beveled  from  above 
downward  and  inward  and  offer  no  obstacle  to  the  uptvard  dislocation 
of  the  outer  end  of  the  clavicle.  This  fact  explains  why  this  is  the 
common  form  of  dislocation  in  this  joint.  The  capsule  and  ligaments 
of  the  joint  proper  are  lax  and  weak  so  that  effusion  into  the  joint  is 
soon  visible.  It  is  the  strong  coracoclavicular  ligament  (coronoid  and 
trapezoid)  upon  which  the  strength  of  the  connection  between  clavicle 
and  scapula  depends. 

The  upward  dislocation  of  the  outer  end  of  the  clavicle  may  be  com- 
plete or  partial  and  in  tiie  former  case  the  coracoclavicular  as  well  as  the 
acromioclavicular  ligaments  are  torn,  in  the  latter  case  the  former  may 
be  torn  or  merely  stretched.  In  complete  dislocation  the  outer  end  of 
the  clavicle  rides  up  above  the  acromion  and  may  be  displaced  outward 
over  the  latter.  The  cause  is  usually  a  blow  upon  the  point  of  the 
shoulder,  probably  associated  with  a  vigorous  contraction  of  the  tra- 
pezius, whereby  the  clavicle  is  prevented  from  becoming  depressed  with 
the  acromion.  The  rarity  of  downward  or  subacromial  dislocation  of  the 
outer  end  of  the  clavicle  is  explained  by  the  oblique  direction  of  the 
joint  surfaces.  The  cause  in  most  cases  was  direct  violence  applied  to 
the  outer  end  of  the  clavicle. 

Whereas  reduction  is  commonly  easy  in  both  forms,  retention  is  diffi- 
cult, as  there  is  nothing  in  the  shape  of  the  bones  to  hold  them  together 
and  the  ligaments  are  torn.  In  the  common  upward  form  upward 
pressure  of  the  shoulder  through  the  arm  and  downward  pressure  on 
the  outer  end  of  the  clavicle  are  accomplished  by  various  retentive 
dressings  but  the  necessary  continuous  retention  is  very  difficult.  As 
in  dislocation  of  the  sternoclavicular  joint  the  injection  of  irritants, 
like  50  per  cent,  alcohol,  to  stimulate  periarticular  connective  tissue 
formation  which  afterwards  contracts  and  helps  to  hold  the  bones 
together,  I  have  found  useful,  especially  in  the  incomplete  forms. 
Some  patients  are  seriously  disabled  by  this  accident,  others  but  little. 

In  this  connection  it  may  be  noticed  that  the  movements  of  this  joint 
allow  the  glenoid  cavity  to  maintain  or  alter  its  rehdire  position  in  the 
movements  of  the  shoulder  around  the  sternoclavicular  joint  as  a  cen- 
ter. Thus  in  raising  the  arm,  forward  or  laterally,  the  extent  of  this 
movement  is  much  increased  by  the  elevation  of  the  glenoid  cavity, 
the  scapula  moving  on  an  antero-posterior  axis  through  this  joint. 
Again  as  the  shoulder  moves  forward  for  a  blow  or  shove  or  in  a  fall 
upon  the  hand  the  glenoid  cavity  is  turned  forward,  so  that  it  may  be 
as  nearly  as  possible  at  right  angles  to  the  long  axis  of  the  iiumerus 
which  it  can  thus  best  support.  In  this  way  a  strong  forward  ''blow 
from  the  shoulder"  is  possible.  Otherwise  the  strain  comes  upon  the 
capsule  of  the  shoulder  and  tends  to  dislocate  it.  This  forward  posi- 
tion of  the  glenoid  cavity  is  due  to  a  movement  of  the  scapula  on  a 
vertical  axis  passing  through  this  joint.  Im])airment  of  this  joint  by 
accident  or  disease  may  therefore  cause  a  limitation  in  certain  move- 
ments of  the  u})per  limb  or  an  insecurity  of  the  shoulder  joint. 


THE  POSTERIOR   OR  SCAPULAR  RFJilOS.  155 

Subclavicular  Soft  Parts. — The  interspace  between  the  aferiKd  and 
clavicular  portion.s  of  the  jx'cforalis  major  can  often  be  distinguislied 
on  the  surface  just  below  the  clavicle.  The  sternal  portion  is  often 
removed  in  whole  or  in  part  in  the  operation  for  carcinoma  of  tlie 
breast.  The  clavicular  portion  is  the  more  superficial  of  the  two.  The 
pectoral  fascia  is  firmly  connected  with  the  pectoralis  major.  AVe  may 
usuallv  be  sure  that  we  have  divided  the  pectoralis  major  when  we 
reach  a  cellular  layer,  though  Heath  describes  a  cellular  interval  which 
sometimes  lies  between  two  planes  of  its  muscle  fibers  and  may  be  mis- 
taken for  the  space  beneath  it.  On  removal  of  tiie  pectoralis  major 
we  expose  the  pectoralis  minor  from  whose  upper  border  a  strong  fascia, 
tlie  clavipectoral  fascia,  extends  up  to  and  is  continuous  with  the  sheath 
of  the  subclavius  muscle  and  thence  is  connected  with  the  clavicle  and 
coracoid  process.  It  is  continuous  with  the  sheath  of  the  axillary 
vessels  and  the  deep  cervical  fascia.  The  upper  part  of  this  fascia, 
between  the  coracoid  process  and  the  first  rib,  is  particularly  firm  and 
is  named  the  costocoracoid.  membrane.  This  fascia  is  pierced  by  the 
cephalic  vein,  the  acromiothoracic  artery  and  the  anterior  thoracic 
nerve  and  covers  the  first  portion  of  the  axillary  vessels  and  the  bra- 
chial plexus.  The  clavipectoral  fascia  splits  to  enshcath  the  ijcctoralis 
minor  and  unites  below  it  into  a  single  triangular  sheet  which  extends 
laterally  to  the  sheath  of  the  coracobrachialis  and  inferiorly  to  the 
floor  of  the  axilla,  the  hollow  of  which  it  serves  to  preserve,  hence 
the  name  "  suspeusorj/  ligament  of  the  axilla.''^ 

The  axillary  vein  lies  below  and  internal  to  the  artery  which  it 
overlaps,  owing  to  its  greater  size.  Hence  when  the  axillary  artery  is 
tied  in  its  first  portion  the  aneuriam  needle  is  passed  from  the  vein  side, 
or  lielow,  to  avoid  injury  to  the  vein.  The  axillary  artery  is  crossed  in 
front  by  the  cephalic  vei)i  in  its  passage  to  reach  the  axillary  vein,  but  it 
is  separated  from  this  vein  by  the  clavipectoral  fascia.  A  part  of  or 
the  entire  cephalic  vein  occasionally  crosses  in  front  of  the  clavicle  to 
join  the  external  jugular  vein.  One  of  the  cords  of  the  bracliial  plexus 
lies  in  contact  with  and  on  the  same  plane  as  the  artery  and  may  be 
and  has  been  mistaken  for  it  in  ligation  of  the  artery.  These  main 
vessels  and  nerves  are  surrounded  by  more  or  less  areolar  and  fatty 
tissue  containing  lymphrdic  vessels  and  nodes  which  may  be  involved 
secondarily  to  those  of  the  axilla  with  which  they  are  continuous. 
They  communicate  with  the  supraclavicular  nodes  above.  Along  this 
areolar  tissue  deep  infection  and  al>scess  may  extend  from  the  neck  to 
the  axilla  and  vice  versa. 

The  Posterior  or  Scapular  Region. 
The  skin  covering  this  region  is  firm  and  there  is  but  little  subcu- 
taneous tissue.  The  thick  deep  fascia,  by  its  attachment  to  bone  around 
the  origin  of  the  supra-  and  iufra-spiuatus  and  the  teres  minor  muscles 
wliicli  it  covers,  encloses  them  in  an  osseo-aj/o neurotic  eomixirfment,  o}>en 
only  toward  the  insertion  of  the  muscle  on  the  great  tuberosity  of  the 
humerus.     Hence  in  case  of  abscess  under  these  fasciae  or  ecchvmosis 


156  THE   UPPER  EXTREMITY. 

from  fracture  of  the  scapula  the  pus  or  blood  cannot  readily  reach  the 
surface,  but  follows  the  muscle  sheaths  to  the  humeral  head  and  appears 
under  the  head  of  the  deltoid.  The  firitmcHS  of  this  fascia  is  such  that 
it  is  difficult  to  decide  whether  dense  tumors  growing  from  it  are  con- 
nected with  the  fascia  or  the  bone.  The  scapula  is  Iwld  in  place  by 
the  coraco-  and  acromioclavicular  ligaments  and  by  the  serratus  mag- 
nus,  rhomboids,  trapezius  and  levator  scapulae  muscles.  The  so-called 
^'winged  scapu/a,"  or  luxation  of  the  scapula,  in  which  the  lower  part 
of  or  the  entire  vertebral  border  projects  backward  from  the  chest  wall 
is  due  to  pcn'd/ysi.s  of  the  lower  part  or  the  whole  of  the  serratns  magnus 
muscle,  which  is  supplied  by  the  long  thoracic  nerve. 

Fracture  of  the  body  of  the  scapula  is  comparatively  rare,  owing  to 
the  mobility  of  the  bone,  its  thick  muscular  covering,  the  elasticity  of 
the  ribs  beneath  and  the  soft  muscular  pad  of  the  subscapularis  and 
serratus  magnus  between  it  and  the  chest  wall.  In  case  of  fracture  the 
fragments  are  splinted  by  the  muscles  attached  on  both  sides  of  it,  which 
prevent  much  displacement.  The  acromion  is  7nore  exposed  to  injury 
and  fracture  than  other  parts  of  the  bone.  Some  consider  many  cases 
of  supposed  fracture  of  the  acromion  as  examples  of  epiphyseal  separa- 
tion from  the  spine,  which  may  occur  before  the  twentieth  year,  when 
the  epiphyseal  union  ossifies.  But  clinically  most  cases  are  found  to 
be  nearer  the  end  of  the  acromion,  i.  e.,  just  in  front  of  the  acromio- 
clavicular joint.  The  dense  fibrous  tissue,  which  covers  this  process 
and  is  derived  from  the  two  muscles  attached  to  it  (deltoid  and  tra- 
pezius), and  its  dense  periosteum  help  to  explain  why  much  displace- 
ment is  uncommon  and  why  many  fractures  are  subperiosteal  and  crep- 
itus is  wanting.  When  the  fracture  is  in  front  of  the  acromioclavic- 
ular joint  the  deltoid  may  pull  the  fragment  slightly  downward,  but 
there  can  be  no  displacement  of  the  scapula  and  arm.  When  the 
fracture  is  behind  the  joint  the  scapula  may  still  be  connected  by  the 
coracoclavicular  ligaments  to  the  clavicle  and  there  can  be  but  little 
if  any  displacement  of  the  arm.  Bony  union  is  said  to  be  the  excep- 
tion. It  should  be  remembered  that  in  some  cases  the  union  of  the 
acromion  and  spine  does  not  ossify,  so  that  the  presence  of  motion  and 
a  fibrous  union  between  these  two  parts  does  not  necessarily  imply 
fracture  or  an  epiphyseal  separation. 

Fracture  of  the  coracoid  process  may  occasionally  occur  as  a  result  of 
violence  or  muscular  action.  Usually  it  is  only  one  of  several  frac- 
tures resulting  from  severe  violence.  In  some  cases  the  line  of  frac- 
ture, being  near  the  base  of  the  process  in  the  line  of  the  epiphyseal 
cartilage,  which  ossifies  during  the  fifteenth  year,  has  suggested  that 
the  case  was  one  of  epiphyseal  separation.  Although  three  powerful 
muscles  are  attached  to  the  coracoid  process  displacenient  is  usually 
slight  owing  to  the  attachment  of  the  coracoclavicular  ligaments  which 
are  seldom  torn. 

The  rare  fracture  of  the  surgical  neck  of  the  scapula  involves  the 
separation  of  the  coracoid  process  and  tlie  glenoid  fossa,  together  with 
the  triceps  attachment,  from  the  rest  of  the  bone.     The  arm  is  displaced. 


J 


THE  EXTERNAL   OR  DELTOID  REGION.  157 

downward  as  in  a  .subglenoid  dislocation,  but  the  eoracoclavicular, 
coracoacromial  and  spinoglenoid  ligaments  are  usually  untorn  and 
limit  the  displacement.  It  is  easily  distinguished  from  dislocation  of 
the  humerus  by  crepitus,  the  ease  of  reduction  and  the  equal  ease  of 
recurrence  of  the  displacement. 

Tumors  of  various  kinds,  especially  osteoma,  enchondroma  and 
sarcoma,  grow  from  the  scapula  and  require  partial  or  complete 
excision.  In  partial  excision  those  parts  which  are  of  special  impor- 
tance for  the  function  of  tlic  arm — /*.  e.,  the  glenoid  fossa,  coracoid  and 
acnjiuion  processes,  should  be  preserved  if  possible.  The  entire  bone 
is  removed  with  or  without  the  arm  in  sarcoma.  In  malignant  tumors 
of  the  upper  end  of  the  humerus  and  some  sarcomas  of  the  axilla  the 
upper  extremity,  scajuda  and  outer  two  thirds  of  the  clavicle  are 
removed  (interscapulotboracic  amputation  of  the  arm),  after  first  ligat- 
ing  the  subclavian  artery.  The  latter  renders  the  operation  bloodless 
except  for  the  posterior  scapular  artery  along  the  vertebral  border  and 
the  suprascapular  artery  in  the  supra-  and  infraspinatus  fossse,  these 
arteries  being  branches  of  the  first  portion  of  the  subclavian.  In 
complete  excision  of  the  scapula  (without  ligature  of  the  subclavian) 
the  subscapular  artery,  which  runs  along  the  lower  border  of  the  sub- 
scapularis  muscle  and  gives  off  the  large  dorsalis  scapuke  branch  cross- 
ing the  axillary  border  onto  the  infras])inatus  fossa,  must  also  be  taken 
into  account.  This  branch  of  the  axillary  artery  aiia.Htontoses  v'lih  the 
posterior  scapular  and  suprascapular  branches  of  the  subclavian  and  is 
an  important  factor  in  the  collateral  circulation  after  ligature  of  the 
third  portion  of  the  subclavian  or  the  first  portion  of  the  axillary 
artery.  The  anastomoses  on  the  acromion  between  the  suprascapular 
branch  of  the  subclavian  and  the  acromiothoracic  and  circumflex 
branches  of  the  axillary  assist  in  this  anastomosis.  For  re-section  of 
the  scapula  a  horizontal  incision  along  the  spine  and  a  vertical  one 
along  the  verteV)ral  border  (Ollier's)  are  very  serviceable. 

The  suprascapular  nerve  is  a  branch  of  the  fifth  cervical  and  receives 
a  branch  from  the  third  and  fourth  cervical  nerves,  from  which  is 
derived  the  phrenic  nerve.  The  latter  also  communicates  with  the 
nerve  to  the  subclavius  and  these  two  connections  explain  the  rejlex 
rrkitio)is  between  the  diai)hragm  or  liver  and  the  shoulder,  i.  c., 
hiccough  from  inflammation  of  the  shoulder  and  pain  in  the  right 
shoulder  in  perihepatitis,  etc. 

The  External  or  Deltoid  Region. 

This  is  equal  in  extent  to  that  of  the  deltoid  muscle  which  covers 
the  upper  end  of  the  humerus  and  the  muscles  inserted  into  it,  the 
shoulder  joint,  the  coracoid  process  and  its  muscles  and  the  coraco- 
acromial ligament.  The  sidjcutaneous  fatty  layer  over  the  deltoid  is 
often  well  developed  and  is  a  favorite  situation  for  lipoma.  The  deep 
Jascia  ensheaths  the  deltoid  and  is  closely  bound  to  it.  In  subglenoid 
or  subcoracoid  dislocation  of  the  shoulder  the  head  of  the  humerus  no 
longer  bolsters  out  the  deltoid,  so  that  the  latter  is  flattened  and  hangs 


158  THE   UPPER  EXTREMITY. 

straight  down  from  the  acromion  process,  which  is  thereby  rendered 
more  prominent  aiid  angnlar.  Moreover  the  attachments  of  the  del- 
toid being  more  widely  separated  than  normal  the  muscle  is  put  on  the 
stretch  which  still  further  flattens  the  region  and  causes  a  notch  or 
fold  at  the  insertion  of  the  muscle.  To  relax  the  deltoid  the  dislo- 
cated arm  is  usually  held  in  the  abducted  position.  If  this  position  is 
exaggerated,  so  that  the  deltoid  is  very  lax,  the  fingers  may  be  thrust 
beneath  the  acromion  into  the  gap  left  by  the  dislocated  head  of  the 
humerus  and  in  thin  subjects  the  glenoid  cavity  may  even  be  felt. 

The  deltoid  region  may  he  flattened  and  a  depression  be  felt  beneath 
the  acromion  in  certain  cases  where  the  head  sinks  away  from  its  socket 
owning  to  paralysis  and.  atrophy  of  the  muscle,  which  is  supplied  by  the 
circumflex  nerve.  (Fig.  40.)  This  nerve  lainds  around  the  surgical 
neck  of  the  humerus  a  little  above  the  posterior  circumflex  artery, 
which  is  two  inches  below  the  acromion.  This  nerve  may  be  torn, 
bruised  or  stretched  in  dislocations  of  the  shoulder,  in  violent  attempts 
at  their  reduction  and  in  fractures  of  the  surgical  neck  of  the  humerus, 
and  it  may  very  rarely  be  bruised  in  contusion  of  the  shoulder.  As 
it  also  supplies  the  shoulder  joint  an  inflammation  of  the  latter  extend- 
ing along  the  nerve  may  cause  a  neuritis  and  lead  to  paralysis  of  the 
muscle  (Erb).  This  nerve  also  gives  oif  a  cutaneous  branch  which, 
winding  around  the  posterior  border  of  the  muscle,  supplies  the  skin 
over  its  lower  third  (and  below  it).  Thus,  according  to  Anger,  we  may 
test  the  sensibility  of  this  cutaneous  branch  after  dislocations  of  the 
shoulder  and  thereupon  base  our  prognosis  as  to  the  future  condi- 
tion of  the  muscle,  for  it  is  not  infrequently  paralyzed  temporarily  or 
permanently. 

The  deltoid  is  not  the  only  abductor  of  the  arm,  being  assisted  by 
the  supraspinatus,  but  in  paralysis  of  the  deltoid  the  power  of  abduc- 
tion is  slight.  In  excision  of  the  shoulder  joint  the  nearer  the  incision 
is  made  to  the  anterior  border  of  the  deltoid  the  less  of  the  muscle  will 
be  paralyzed  by  cutting  its  nerve  supply  and  the  smaller  will  be  the 
branches  of  the  posterior  circumflex  artery  to  be  divided. 

Beneath  the  deltoid,  in  the  layer  of  loose  connective  tissue  which 
facilitates  the  movements  of  the  underlying  head  of  the  humerus,  is 
the  subdeltoid  or  subacromial  bursa,  which  still  further  facilitates  these 
movements.  As  its  name  implies  this  bursa  also  extends  beneath  the 
acromion  process  and  this  portion  is  sometimes  partly  separated  from 
the  subdeltoid  portion  by  a  constriction.  Beneath  the  bursa  are  the 
great  tul)erosity  of  the  humerus  and  the  supraspinatus  tendon,  but 
there  is  )io  comviunication  ivith  the  joint  unless  in  dislocation  when  the 
supraspinatus  tendon  is  ruptured.  This  bursa  may  hold  about  an 
ounce  when  distended  with  fluid,  as  it  sometimes  is,  causing  an  undue 
prominence  of  the  deltoid.  In  case  of  abscess  of  this  bursa  the  pus 
may  reach  the  surface  at  either  edge  of  the  muscle,  usually  the  ante- 
rior edge,  rarely  through  it.  From  the  point  of  view  of  operative 
incision  the  shoulder  joint  is  o)dy  covered  by  the  skin,  the  deltoid  and 
the  capsule. 


PLATE    XV 


FIG.  4-0. 


SUBSCAPULAR 
ARTERY 


CIRCUM  FLEX 
NERVE 


POSTERIOR    CIRCUM- 
FLEX   ARTERY 


■•■  USCULO-SPIRAL 
NERVE 

SUPERIOR 
PROFUN  DA 
ARTERY 


Posterior  region  of  the  shoulder";    right  side. 
(Joessei.) 


THE  SHOULDER  JOINT.  159 

The  shoulder  joint  is  one  that  relies  for  its  fifrenrjth  largely  upon  the 
surrounding  niu.selcs,  a  variety  of  joint  most  fiablr  fo  fJix/omtion.  The 
laxity  of  the  capsule  and  the  fact  that  the  articular  surfaces  are  held 
together  by  atmospheric  pressure  is  shown  by  the  admission  of  air  into 
the  joint,  dissected  free  of  its  muscular  covering.  Thereupon  the  head 
of  the  humerus  falls  away  from  the  glenoid  cavity  by  a  considerable 
interval.  The  same  occurs  in  cases  of  old  standing  paralysis  of  the 
deltoid.  The  acromion  and  coracoid  processes,  and  the  coracoacromial 
ligament  connecting  them,  form  an  arch  above  the  joint,  protecting  it  but 
separated  from  it  by  the  interposed  tendon  of  the  supraspinatus  and 
the  capsule. 

The  muscles  strengthening  the  capsule  are  the  subscapularis  in  front, 
the  supraspinatus  above  and  the  infraspinatus  and  teres  minor  behind. 
The  tendons  of  these  muscles  are  blended  vith  the  capsule  in  their  pas- 
sage to  the  small  and  great  tuberosities  of  the  humeral  head.  They 
are  continuous  with  one  another  and  are  assisted  in  supporting  the 
joint  by  the  long  head  of  the  triceps  below  and  the  long  head  of  the 
biceps  above.  The  latter  tendon  in  its  passage  through  the  bicipital 
groove,  which  is  converted  into  a  canal  by  the  transverse  ligament,  is 
accompanied  bv  a  tubular  pyrolonfjaiion  of  the  synovial  membrane  form- 
ing  a  kind  of  vaginal  sheath  for  it.  There  is  another  constant  gap  in 
the  capsule  by  which  the  synovial  sac  communicates  with  the  sub- 
scapular bursa,  a  large  pouch  between  the  upper  part  of  the  subscapu- 
laris and  the  root  of  the  coracoid  process  together  with  the  adjoining 
part  of  the  neck  of  the  scapula.  The  crescentic  gap  leading  from 
the  joint  into  the  bursa  lies  just  in  front  of  the  upper  end  of  the  inner 
margin  of  the  glenoid  cavity,  between  the  superior  and  middle  gleno- 
humeral  bands.  A  bursa  beneath  the  infraspinatus  rarely  communi- 
cates with  the  joint.  In  addition  the  capjsule  is  unprotected  antero- 
inferiorly  between  the  subscapularis  and  the  long  head  of  the  triceps, 
where  the  head  can  be  felt  by  the  hand  in  the  axilla. 

The  axillary  vessels  and  nerves  (Fig.  41)  lie  to  the  inner  side  of  the 
joint,  separated  from  it  by  the  subscapularis  tendon.  In  joint  di.seasewith 
eifusion  the  shoulder  appears  full  and  rounded  by  reason  of  the  dis- 
tended capsule,  which  may  cause  a  separation  of  the  two  bones  of  more 
than  one  half  inch  (Braune).  In  artificial  distension  the  arm  becomes 
slightlv  extended  and  rotated  i)iivard,  a  position  commonly  found  in 
joint  disease  and  perhaps  due  to  the  rigid  contraction  of  the  muscles, 
of  which  the  latissimus  dorsi  may  have  a  sliglit  advantage  and  be 
responsible  for  the  extension  and  inward  rotation.  Special  prom- 
inences occur  in  the  bicipital  and  subscapular  diverticula.  Thus  a 
swelling  often  appears  at  an  early  stage  ///  thr  groove  between  the  deltoid 
and  great  pectoral  muscles.  This  swelling  is  sometimes  bilobed  on 
account  of  the  unyielding  biceps  tendon.  Fluctuation  can  best  he  felt 
through  the  axilla,  at  the  uncovered  part  of  the  capsule  below  the  sub- 
scapularis. If  sup|>uration  occurs  the  jius  usutdli/  escajjes  through  one 
of  the  diverticula,  most  often  the  one  around  the  biceps  tendon.  In 
the  latter  case  it  may  extend  some  distance  along  the  bicipital  groove. 


160  THE   UPPER  EXTREMITY. 

If  it  escapes  through  the  subscapular  bursa  it  is  apt  to  spread  between 
the  muscle  aud  the  scapula  and  point  at  the  lower  and  dorsal  part  of 
the  axilla.  Although  the  shoulder  joint  is  liable  to  all  forms  oi'  Joi)it 
disease  the  latter  are  not  particularly  common  here.  As  the  result  of 
disease  the  various  forms  of  anchi/Iosis  occur  and  in  such  cases  Tillaux 
has  suggested  division  of  the  clavicle  and  the  formation  of  a  false  joint 
to  afford  freer  movement. 

The  long  tendon  of  the  biceps  strengthens  the  upper  part  of  the  joint, 
keeps  the  humerus  against  the  glenoid  cavity,  and  prevents  it  from 
being  pulled  down  when  the  arm  is  abducted.  It  is  rarely  ruptured 
and  seldom  displaced  from  its  groove  unless  one  of  the  tuberosities  is 
torn  away,  as  occasionally  occurs  in  dislocation  of  the  shoulder.  The 
inner  margin  of  the  glenoid  cavity  is  the  stronger  and  more  prominent, 
especially  below,  a  fact  which  indicates  an  attempt  to  fortify  a  weak 
part  of  the  joint  where  the  head  most  often  leaves  the  socket  in  dis- 
location. 

AVhen  the  arm  hangs  at  the  side  the  glenoid  cavity  looks  outward 
and  forward,  nearly  midway  between  the  sagittal  and  frontal  planes  of 
the  body,  and  at  least  two  thirds  of  the  head  of  the  humerus  are  not 
in  contact  with  it.  The  entire  head  is  to  the  outer  side  of  the  cora- 
coid  process  in  this  position.  The  glenoid  fossa  is  less  than  half  as 
large  as  the  articular  portion  of  the  head  of  the  humerus  on  horizon- 
tal section  and  about  two  thirds  as  large  on  vertical  section.  Thus  a 
considerable  portion  of  the  head  of  the  humerus  is  always  in  contact 
with  the  capsule  and  in  abduction  of  the  arm  to  90°  the  head  of  the 
bone  presses  against  and  puts  on  the  stretch  the  lower  unprotected 
part  of  the  capsule,  between  the  subscapularis  and  triceps  tendons. 
It  is  in  this  position,  with  or  without  outward  rotation,  that  dislocation 
of  the  shoulder  is  most  likely  to  occur. 

In  abduction  of  the  arm  to  a  right  angle  the  great  tuberosity 
abuts  against  the  upper  edge  of  the  glenoid  cavity  and  the  upper  end 
of  the  outer  aspect  of  the  humerus  against  the  coracoacromial  arch. 
Further  (ibduction  is  due  to  the  rotation  of  the  scapula,  but  if  the  latter 
is  kept  from  rotating  by  being  held  mechanically  or  by  a  muscular 
spasm  (serratus  raagnus)  and  if  the  motion  of  abduction  is  continued 
a  neiv  center  of  motion  is  formed  at  the  point  of  contact  of  the  hu- 
merus with  the  coracoacromial  arch  and  the  head  is  forced  down 
against  the  lower  and  inner  tense  part  of  the  capsule,  rupturing  it. 
Such  is  the  common  mechanism  of  dislocation  in  cases  due  to  indirect 
or  to  muscular  violence. 

The  infrequency  of  the  injury  in  i\\e  first  two  decades  of  life  is  inter- 
esting in  connection  with  Kronlein's  theory  that  in  this  period  fracture 
of  the  clavicle  is  the  equivalent  of  dislocation  of  the  shoulder  by  direct 
violence,  and  dislocation  of  the  elbow  the  equivalent  of  dislocation  of 
the  shoulder  by  indirect  violence. 

Dislocations  of  the  shoulder  are  as  numerom  as  all  other  disloca- 
tions combined,  ])erhaps  more  so.  This  frequency  is  fully  explained 
by  (1)  the  structure  of  the  joint  (the  shallowness  of  the  glenoid  fossa, 


DISLOCATIONS  OF  THE  SHOULDER.  101 

the  large  size  of  the  humeral  head,  the  freedom  of  motion,  the  long 
leverage  of  the  arm,  the  laxity  of  the  capsule  and  its  dei)endence  upon 
the  muscles  for  its  strength) ;  and  {'!)  the  exposure  of  the  shoulder  to 
indirect  and  direct  violence.  Dislocations  of  the  shoulder  are  clas- 
sified, according  to  the  dinplacemeid  of  the  humeral  head,  into  (1) 
anterior  or  subcoracoid,  the  common  form,  (2)  downward  or  sub- 
glenoid, not  common,  (.">)  backward  or  subacromial,  rare,  and  (4)  up- 
ward or  supraglenoid,  very  rare.  Only  the  first  two  forms  demand 
our  consideration. 

In  subcoracoid  dislocations  the  head  of  the  humerus  escapinrj 
through  thf  rent  in  tiie  antcro-inferior  part  of  the  capsule  is  displaced 
primarily  downward  and  somewhat  forward.  Indeed  some  downward 
displacement  is  necessary  to  allow  the  head  to  get  beneath  the  coracoid. 
But  the  further  downward  displacement  is  resisted  by  the  untorn  part 
of  the  capsule  (outer  and  anterior  parts)  whose  attachment  to  the  ana- 
tomical neck  serves  as  a  new  center  of  motion,  so  that  when  the  elbow 
is  lowered  after  abduction  has  ceased,  the  head  rises  along  the  inner 
side  of  the  joint.  This  secondary  displacement  to  a  final  position,  ap- 
proximately beneath  the  coracoid  (subcoracoid),  is  also  partly  effected 
by  the  contraction  of  such  mnticle.s  as  the  i)ectoralis  major,  latissimus 
dorsi  and  deltoid.  The  extent  of  this  secondary  inward  displacement 
is  determined  largely  by  the  resistance  of  the  untorn  portion  of  the 
capsule,  the  continuance  of  the  dislocating  violence,  and  the  degree  of 
contraction  of  the  adductor  muscles.  Thus  the  head  maybe  displaced 
internal  to  the  coracoid  process,  giving  rise  to  the  subvariety  "  intra- 
coracoid." 

In  the  subcoracoid  form  the  Jiead  of  the  bone  lies  behind  the  coraco- 
brachialis  and  the  short  head  of  the  biceps  and  against  the  edge  of  the 
glenoid  fossa  or  the  side  of  the  neck  of  the  scapula  just  internal  to  it. 
In  the  intracoracoidal  variety  it  lies  farther  back  on  the  neck  and  against 
the  serratus  magnus,  having  passed  behind  the  muscles  arising  from 
the  coracoid  process.  The  head  is  thus  internal,  anterior  and  a  little 
inferior  to  its  normal  position.  The  anatomical  neck  may  rest  on  the 
anterior  lip  of  the  glenoid  cavity. 

The  subscapularis  muscle  is  sometimes  pressed  inward  and  separated 
from  the  scapula  by  the  interposed  humeral  head,  but  in  many  cases 
it  is  torn  from  its  lower  border  upward  to  a  greater  or  less  extent. 
Thus  tiie  subscapularis  may  intervene  in  whole  or  in  part  between  the 
coracoid  process  and  the  head,  or  the  latter,  escaping  in  front  of  the 
muscle,  may  lie  close  against  the  beak  of  the  coracoid,  behind  the 
coracobrachialis  and  short  head  of  the  biceps.  The  attachment  to  the 
humerus  of  the  sapra.ytinatKs  is  j>rol)ably  often  torn,  that  of  the  infra- 
spinatus less  often,  or,  in  place  of  this  rupture  of  the  tendon,  the  great 
tuberosity  may  be  torn  off.  This  latter  accident  is  of  importance  be- 
cause it  opens  the  way  for  the  long  biceps  tendoti  to  escape  from  its 
groove,  slip  over  the  head  and  become  engaged  between  the  head  and 
the  glenoid  cavity,  wliere  it  may  offer  a  serious  obstacle  to  reduction. 
The  rupture  or  avulsion  of  the  s}ij>r(i-  and  infrasj)iii(dus  foidons,  and 
11 


162  THE   UPPER  EXTREMITY. 

their  consequent  retraction  under  the  acromion,  may  impair  the  subse- 
quent motion  of  the  joint  by  their  loss  of  control  over  the  humerus. 
They  may  become  interposed  between  the  head  and  its  socket,  so  as  to 
oppose  reduction,  or  they  may  open  up  the  subdeltoid  bursa  and  favor 
the  recurrence  of  dislocation  by  lengthening  and  weakening  the  cap- 
sule. The  axillary  vessels  and  nerves  are  pressed  inward  and  sometimes 
ruptured. 

In  the  subglenoid  variety  the  head  usually  re.sis  against  the  flat- 
tened upper  end  of  the  axillary  border  of  the  scapula  on  the  inner  side 
of  the  triceps  tendon,  the  latter  preventing  its  displacement  directly 
downwards.  It  thus  lies  below  and  a  little  internal  and  anterior  to  its 
normal  position.  It  also  lies  beneath  the  subscapularis  tendon,  which 
is  much  stretched  or  torn.  The  rent  in  the  capsule  differs  from  that  in 
the  subcoracoid  form  in  not  extending  so  far  upward  along  the  anterior 
edge  of  the  glenoid  cavity.  The  resistance  of  this  untorn  anterior  part 
of  the  capsule  seems  to  be  what  prevents  the  head  from  reaching  the 
subcoracoid  position,  although  in  some  cases  this  dislocation  may  be 
transformed  into  a  subcoracoid  by  movements  of  the  arm  or  even  by 
muscular  action.  The  supraspinaius  and  often  the  infraspinatus 
are  torn  from  their  attachments,  or  the  tuberosity  is  avulsed  from  the 
humerus.  The  cause  of  the  subglenoid  form  has  almost  always  been 
a  forcible  elevation  of  the  arm. 

The  symptoms  in  both  forms  are  mainly  due  to  the  absence  of  the 
head  from  its  normal  position,  the  presence  of  the  head  in  an  abnormal 
position  and  the  consequent  altered  position  or  action  of  the  muscles. 
The  absence  of  the  head  from  its  socket  accounts  largely  for  the  flatten- 
ing of  the  deltoid  region  and,  in  the  subcoracoid  form,  the  empty  glenoid 
socket  can  be  felt  through  the  axilla.  In  the  subglenoid  form  we  can 
feel  the  head  tlirough  the  axilla,  lying  below  the  glenoid  fossa  i— 1  inch 
below  the  coracoid  process,  while  in  the  subcoracoid  form  it  forms  a 
hard  prominence  of  the  anterior  axillary  wall,  just  below  the  coracoid 
process,  and  causes  a  fullness  of  the  outer  part  of  the  infraclavicular 
fossa.  The  axis  of  the  arm  prolonged  upward  passes  below  or  internal 
to  the  glenoid  cavity.  The  deltoid  is  stretched  by  the  increased  separa- 
tion of  its  attachments,  and  this  not  only  increases  the  flatteidnc/  of  the 
deltoid  region  and  the  prominence  of  the  acromion  but  causes  the  arm 
to  be  abducted,  Avhich  is  more  marked  in  the  subglenoid  variety  as  the 
deltoid  is  more  stretched. 

As  the  head  is  displaced  somewhat  downward  in  both  forms,  viea,s- 
urement  from  the  angle  of  the  acromion  to  the  external  condyle  of  the 
humerus  should  show  lengthening  as  compared  with  the  opposite  limb. 
But  owing  to  the  relativ^e  position  of  these  two  points  of  measurement 
in  a  plane  external  to  that  of  the  glenoid  cavity,  abduction  causes  a 
measured  shortening  in  the  normal  arm  and  nuich  more  so  in  the  dis- 
located arm,  when  the  head  is  displaced  more  or  less  inward.  Hence 
the  measured  lengthening  will  depend  on  the  degree  of  abduction  and 
may  be  altogether  wanting  or  replaced  by  shortening,  though  seldom 
so  in  the  subglenoid  form,  in  spite  of  its  greater  abduction,  on  account 


REDUCTION  OF  DISLOCATfOX  OF  SHOULDER  163 

of  its  greater  lengthening.  The  elbow  can  not  be  made  to  touch  the 
thorax  for,  on  account  of  the  rotundity  of  the  thorax,  both  ends  of 
the  straight  luimerns  can  not  touch  it  at  the  same  time,  and  in  a  dis- 
location of  the  shoulder  the  head  of  the  bone  is  ])ractically  touching 
the  thorax.  The  diagnosis  between  subcoracoid  and  subglenoid  dis- 
locations can  usually  be  readily  made  from  the  differences  noted  in  the 
symptoms  given  above. 

Reduction. — The  obstacles  to  this  may  be  the  tension  of  the  untorn 
portion  of  the  capsule,  opposing  the  movement  of  the  head  toward  the 
socket,  the  approximation  of  the  sides  of  the  rent  in  the  capsule,  the 
interposition  of  portions  of  the  capsule  or  of  the  biceps  tendon,  the 
contraction  and  rigidity  of  the  muscles,  the  edge  of  the  glenoid  cavity 
and,  rarely,  the  interposition  of  the  subscapularis  tendon. 

The  most  frequent  obstacles  are  the  opposition  of  the  anterior  part 
of  the  capsule  and  the  contraction  of  the  muscles  and  these,  as  well  as 
most  other  obstacles,  may  be  avoided  hi/  abduction  and  outirard  rotation. 
of  the  arm.  Traction  in  this  position,  with  or  without  direct  pressure 
on  the  head  toward  the  glenoid  cavity,  is  successful  in  the  great  majority 
of  cases.  Success  in  methods  employing  traction  is  also  largely  depen- 
dent upon  the  efficient /.ua//o/i  of  the  scapula  by  the  surgeon,  his  assist- 
ant, bandages  or  apparatus.  Stimson  '  has  lately  successfully  employed 
a  modification  of  this  method  by  exerting  continued  traction  by  a 
weight  on  the  abducted  arm,  the  latter  passing  through  a  hole  in  a 
canvas  cot.  The  continued  traction  of  the  weight  tiring  out  the  mus- 
cular contraction,  reduction  occurs  painlessly  and  spontaneously  within 
six  minutes.  Traction  npioard,  though  formerly  emjiloyed,  is  objection- 
able on  account  of  the  risk  of  increasing  the  laceration  of  the  capsule 
and  of  injuring  the  axillary  vessels  by  stretching  them  around  the  head 
of  the  humerus.  Although  this  method  is  theoretically  suggested  by 
the  position  of  the  head  in  the  subglenoid  variety  yet  on  account  of  the 
risks  mentioned  trial  should  first  be  made  of  direct  reposition  by  pressure 
on  the  head,  or  this  combined  with  traction  in  the  abducted  position. 

In  the  methods  of  reduction  by  manipulation,  rotation  inward  has  long 
been  em])loyed  to  turn  the  head  of  the  bone  into  the  socket  opposite  to 
which  it  had  been  brought  by  traction.  Inward  rotation  constitutes 
the  last  step  in  the  pure  manipulative  method  now  most  in  use,  that  of 
Kocher.  In  Kocher's  method  the  flexed  elbow  is  pressed  against  the 
side  (adduction)  and  rotated  ontward  until  the  forearm  points  directly 
outward  ;  the  arm,  rotated  outward,  is  then  carried  forward  and  sli</htli/ 
inward,  and  rotated  inward,  carrying  the  hand  over  to  the  opposite 
shoulder.  Reduction  occurs  in  the  final  rotation  inward  or  in  the 
movement  forward  and  inward.  Farabeuf  thus  explains  the  meclia- 
nism  of  the  nianipididions.  The  untorn  j)()sterior  portion  of  the  c.<(j)sule 
is  the  efficient  agent.  This  is  tightened  by  the  adduction,  so  as  to 
prevent  the  posterior  surface  of  the  humerus  from  moving  inward  or 
forward  when  the  arm  is  rotated  outward.  Hence  the  attachment  of 
this  part  of  the  capsule  serves  as  the  fixed  point  about  which  the  head 
'  Fractures  and  Dislocations,  third  ed.,  p.  505. 


164  THE   UPPER  EXTREMITY. 

rolls  or  winds  outward  in  outward  rotation.  In  the  forward  move- 
ment, with  slight  adduction,  the  head,  turning  upon  the  same  fixed 
point,  is  thrown  backward  and  further  outward  toward  the  socket,  so 
that  the  final  inward  rotation,  unwinding  the  capsule,  leaves  the  head 
in  place.  This  method  is  also  ajjplicable  to  old  cases  but  there  is  some 
danger  of  fracture  of  the  humerus  in  the  outward  rotation. 

Associated  injuries  and  complications  of  dislocation  of  the  shoulder, 
in  addition  to  those  mentioned,  may  occur  either  at  the  time  of  disloca- 
tion or  during  reduction  and  it  is  often  difficult  to  say  at  which  time  a 
given  complication  has  occurred.  Fracture  of  the  anatomical  or  surgical 
neck  is  indicated  by  the  failure  of  the  head,  which  is  out  of  the  socket, 
to  share  the  movements  of  the  arm.  The  dislocated  and  fractured 
fragment  may  sometimes  be  reduced  by  direct  pressure.  Failing  in 
this  the  following  plans  were  formerly  tried  :  (1)  Consolidation  of  the 
fracture  and  then  reduction  ;  (2)  prevention  of  union  and  the  formation 
of  a  false  joint ;  (3)  excision.  But  open  incision  is  preferable  and, 
in  fractures  of  the  surgical  neck,  McBurney  has  demonstrated  tlie  ser- 
vice, in  accomplishing  reduction,  of  a  stout  bent  hook  introduced  into 
a  hole  drilled  in  the  upper  fragment.  Fracture  of  the  neighboring 
processes  or  of  the  shaft  have  also  been  observed. 

Injury  to  the  nerves,  except  of  a  slight  and  transitory  nature,  are 
nof  coinrnoit ;  they  occur  most  often  during  reduction  and  in  the  subgle- 
noid variety  in  which  the  nerves  are  tightly  stretched  around  the  head. 
Tiie  circumflex  nerve  (see  also  p.  158)  suffers  most  often  and  has  been 
entirely  or  partly  ruptured,  stretched  or  compressed.  The  main  nerve 
trunks  have  also  been  compressed. 

Serious  injury  to  the  blood  vessels  are  not  common,  and  it  is  often 
doubtful  whether  the  injury  occurred  during  the  dislocation  or  its  re- 
duction. The  axillary  vein  alone  has  been  ruptured  in  four  cases,  the 
vein  and  artery  in  two,  but  in  the  majority  the  axillart/  artery  or  one  of 
its  branches  has  been  the  vessel  injured.^  In  some  of  the  latter  there 
was  a  complete  or  partial  rupture  of  all  of  the  coats  of  the  artery, 
while  in  others  the  coats  were  so  injured  that  rupture  or  the  formation 
of  an  aneurism  followed  later.  The  rupture  is  usually  high  up  where  the 
head  pressed  inward  upon  the  vessel  and  in  some  cases  it  appeared  to  be 
due  to  the  tearing  off  of  a  branch,  the  subscapular  or  circumflex  which 
run  almost  directly  outward  where  they  are  fixed  to  the  tissues  among 
which  they  branch.  Again  the  latter  branches  have  been  torn  across  at 
or  near  their  origin,  in  which  case  the  radial  pulse  would  persist.  In 
old  disloc<dions  the  vessels,  especially  the  outermost  one,  the  artery, 
becoming  adherent  to  the  bone,  are  more  likely  to  be  ruptured  in  reduc- 
tion for  the  strain  comes  on  a  shorter  segment  of  the  vessel,  i.  e.,  the 
segment  above  the  adhesion  to  the  bone.  If  the  vessel  is  atheromatous 
tiie  danger  is  still  greater. 

Fracture  of  the  anatomical  neck  without  an  additional  line  of 
fracture  through  the  tuberosities  is  a  rare  and  obscure  form  of  injury 
and  occurs  most  often  in  connection  with  dislocation  of  the  shoulder. 
'Stimson,  Fractures  and  Dislocations,  third  ed.,  p.  453. 


SEPARATION  OF  THE   UPPER  EPIPHYSIS.  165 

When  the  line  of  fracture  passes  through  the  tuberosities  the  outer 
part  of  it  is  extracapsular,  for  the  outer  part  of  the  capsule  is  at- 
tached exactly  to  the  anatomical  neck,  while  internally  it  is  attached 
some  distance  below  it.  From  the  latter  point  capsular  libers  are 
reflected  upward  to  the  lower  margin  of  the  articular  head  and  these 
fibers  blend  with  the  periosteum  and  usually,  but  not  always,  connect 
the  head  with  the  shaft  in  fracture  of  the  anatomical  neck.  When  the 
head  has  a  slight  vascular  connection  with  the  rest  of  the  bone,  and 
probably  when  it  has  none,  the  head  does  not  necessarily  necrose  but 
repair  U  jjo.s.-<ih/<\,  being  carried  on  largely  by  the  lower  fragment. 

The  si/mptomti  are  obscure.  Crepitus  may  be  absent  owing  to  impac- 
tion or  the  ease  with  which  the  small  upper  fragment  within  the  socket 
shares  the  movement  of  the  lower  fragment.  The  loicer  fragment  may 
be  displaced  upward  and  backward  by  the  action  of  the  deltoid  and 
other  muscles  and  in  this  case  there  is  likely  to  be  slight  shortening  of 
the  arm.  Again  the  upper  end  of  the  lower  fragment  may  be  displaced 
forward  and  inward  by  the  muscles  attached  to  the  bicipital  ridges  and 
groove.  Up  and  down  movements  of  the  lower  fragment  may  be  un- 
usually free  and  accompanied  by  pain  and  possibly  by  crepitus.  If 
impaction  of  the  fragments  occurs,  as  it  may  readily  do,  there  may  be 
some  flattening  of  the  deltoid. 

Separation  of  the  upper  epiphysis  may  take  place  at  any  time 
from  birth  to  the  time  when  its  conjugal  cartilage  ossifies,  usually  by 
the  twentieth  year,  sometimes  as  late  as  the  twenty-fifth.  It  has  beeu 
observed  up  to  the  age  of  nineteen  years.  The  upper  epiphysis  comprh<<€s 
the  head  and  tuberosities  and  its  lower  border  runs  upward  and  out- 
ward along  the  lower  and  inner  half  of  the  anatomical  neck  and  then 
transversely  under  or  through  the  tuberosities  to  the  outer  edge,  where 
it  lies  above  part  of  the  insertion  of  the  teres  minor.  The  upper  end 
of  the  shaft  is  shaped  like  a  low  cone,  the  height  of  the  cone  increasing 
with  age  as  does  the  depth  of  the  corresponding  cup  in  the  head.  The 
epiphyseal  line  is  so  nearly  transverse  that  the  complete  transverse 
displacement  of  the  fragments  can  not  often  occur,  especially  as  the 
periosteum  remains  untorn  to  some  extent,  particularly  posteriorly,  and 
where  it  is  torn  it  is  often  stripped  up  from  the  shaft  and  torn  below 
the  epiphyseal  line. 

Displacement. — The  up})er  fragment  is  usually  abducted,  flexed  and 
rotated  outward  by  the  muscles  attached  to  the  great  tuberosity  while 
the  shaft  is  drawn  forward  and  usually  inward  by  the  muscles  inserted 
into  the  bicipital  ridges  and  groove.  The  anterior  edge  of  the  upper 
end  of  the  shaft  may  form  a  distinct  forward  projection  and  can  usually 
be  plainly  felt  an  inch  or  more  below  the  acromion.  The  injury  may 
occasionally  cause  the  premature  ossification  of  the  conjugal  cartilage, 
and  the  conseriuent  arrest  of  e/rowth  of  the  arm,  for  the  greater  part  of 
the  growth  in  length  of  the  humerus  takes  place  at  its  upper  end.  A 
similar  arrest  of  growth  is  much  more  likely  to  follow  an  inflammation 
of  the  cartilage  (epiphysitis). 

The  displacement  can  usually  be  reduced  by  direct  pressure  on   the 


166  THE    UPPER   EXTREMITY. 

upper  fragment  combined  with  traction  on  the  arm,  preferably  in  the 
completely  abducted  position,  as  the  upper  fragment  is  already  abducted. 

Fracture  of  the  Surgical  Neck. — The  fact  that  the  great  majority 
of  fractures  of  the  upper  end  of  the  humerus  occur  between  the  site  of 
the  epiphyseal  cartilage  and  the  insertion  of  the  pectoralis  and  teres 
major  muscles  has  given  the  natne  "surgical  neck"  to  this  part  of  the 
bone.  A  fall  or  blow,  or  occasionally  muscular  action,  is  the  cause. 
The  upper  end  is  often  fixed  by  the  resistance  of  the  capsule,  the  liga- 
ments and  perhaps  the  muscles,  while  the  elbow  is  forced  in  the  oppo- 
site direction  and  a  blow  is  received  on  the  outer  part  of  the  shoulder 
so  that  a  "  cross  strain  "  is  produced.  Fractures  of  the  lower  part  of 
the  neck  are  more  apt  to  be  oblique. 

The  displacement  is  commonly  as  follows  :  the  upper  fragment  is 
abducted  and  rotated  outward  by  the  muscles  attached  to  the  great 
tuberosity  while  the  lower  fragment  is  drawn  Jipward  by  the  deltoid, 
coracobrachialis  and  triceps,  unless  the  fracture  is  transverse  or  im- 
pacted, and  its  upper  end  is  drawn  inward  by  the  muscles  attached  to 
the  bicipital  groove  and  ridges  and  by  the  continuation  of  the  fractur- 
ing force.  When  so  displaced  the  lower  fragment  may  form  a  pro- 
jection in  the  axilla,  and  be  abducted  so  as  to  alter  the  axis  of  the 
limb.  This  displacement  is  by  no  means  constant  and  in  the  majority 
of  cases  it  is  too  slif/Jit  to  be  clinically  recognizable,  especially  through 
the  swollen  tissues.  I  have  had  one  case  where  the  sharp  u])per  end 
of  the  lower  fragment  perforated  and  buttonholed  the  deltoid,  ante- 
riorly, and  required  an  operation  to  dislodge  and  replace  it. 

Failure  of  the  tuberosities  to  share  the  rotary  movement  imparted  to 
the  elbow  is  one  of  the  characteristic  symptoms.  In  adopting  a  suitable 
dressing  for  these  cases  the  action  of  the  muscles  mentioned  above  as 
producing  the  displacement  must  be  opposed,  which  may  be  partly 
effected  by  using  traction  by  means  of  weights  or  the  weight  of  the  arm. 

Excision  of  the  Shoulder  Joint. — From  an  operative  point  of  view 
the  shoulder  joint  is  covered  only  by  the  skin  and  the  deltoid  muscle 
and  hence  is  very  accessible.  It  is  most  desirable  for  the  subsequent 
function  of  the  arm  to  preserve  the  function  of  the  deltoid  by  sparing 
its  nerve  (the  circumflex)  which  reaches  it  from  behind,  hence  the  in- 
cision should  be  at  or  near  its  anterior  border.  With  this  object  in 
view  the  incision  begins  at  the  edge  of  the  clavicle,  above  the  coracoid 
process,  and  passes  down  along  the  anterior  margin  of  the  deltoid. 
The  pectoralis  major  and  cephalic  vein  are  retracted  internally,  the 
deltoid  externally,  and  the  latter  may  be  detached  for  a  distance  from 
the  clavicle  if  more  room  is  re({uired.  The  acromial  branch  of  the 
acromiothoracic  artery  and  the  coracoacromial  ligament  are  divided. 
The  capsule  is  opened  along  the  long  biceps  tendon  and,  rotating  the 
bone  first  inward  and  then  outward,  the  great  and  then  the  lesser 
tuberosity  is  cleared  of  muscular  attachments  by  vertical  incisions 
close  to  the  bone,  the  ])iceps  tendon  being  drawn  aside.  The  head  can 
then  be  thrust  up  through  the  slit  in  the  capsule  and  the  neck  cleared 
and  divided. 


PLATE    XVr. 


LONG    TEN  DON 

OF    BICEPSI 


CGRACO-BRACHIALIS 
AND    SHORT    HEAD 

OF    BICEPS     ^ 


DELTOID^  I   pt^ 


rrVof 


^(S  rviAJORjs 


SECOND    RIB 

OXILLARY ARTERY  WITH 
N  ERVES  OF  BRACHI- 
AL   PLEXUS 


—  LONG    THORACIC 
NERVE 


FOURTH     RIB 


suprascapular! 

VESSELS 


Horizontal  section  through  the  middle  of  the  glenoid  cavity; 
the  arm  being  adducted,  showing  the  axilla  on  transverse  sec- 
tion.    Right  side,  upper  segment  of  section.     (Testut.) 


THE  AXILLA.  1G7 

A  continuation  of"  tlic  above  incision  for  excision  airord-  f>ne  of  the 
best  methods  (^racket  method)  of  amputation  or  disarticulation  at  the 
shoulder  joint  and  it  allows  an  excision  to  he  followed  by  an  amputa- 
tion if  the  case  demands  it.  The  vertical  incision  is  carried  d(nvn  to  the 
level  of  the  axillary  fold  and  then  curved  outward  through  the  lower 
part  of  the  deltoid  and  around  the  posterior  and  inner  part  of  the  arm 
and  then  upward  under  the  anterior  axillary  fold  to  end  in  the  verti- 
cal incision.  In  the  vertical  incision  the  cephalic  vein  and  branches 
of  the  acromiotlioracic  artery  are  ligated.  After  division  of  the  lower 
part  of  the  deltoid  this  muscle,  with  the  trunk  of  the  posterior  circum- 
flex artery  and  the  circumflex  nerve,  can  be  readily  raised  from  the 
bone  by  blunt  dissection  exposing  the  head,  around  which  the  capsule 
is  divided.  Then  the  muscular  tissues  on  the  inner  side,  with  the 
vessels  and  nerves  they  contain,  are  divided  after  separating  them 
from  the  bone  from  above  downward  to  the  level  of  the  skin  incision. 
In  this  step  the  main  vessels  may  be  controlled  by  an  assistant  com- 
pressing them  in  the  inner  flap  between  the  thumb  and  fingers  of  both 
hands,  or  they  may  he  previousiy  ligated  through  the  skin  incision.  In 
freeing  the  insertions  of  the  teres  muscles  we  must  keep  close  to  the 
bone  to  avoid  the  circumflex  nerve,  which  passes  back  between  them 
to  supply  the  deltoid,  the  chief  muscle  of  the  stump. 

The  Axilla. 

This  pyramidal  space  between  the  chest  and  the  arm  may  be  regarded 
surgically  as  a  passageway  between  the  neck  and  the  upper  extremity 
by  which  tumors  or  abscesses  may  extend  from  the  one  to  the  other 
region. 

Boundaries.  (Fig.  41.) — The  anterior  wall  (Fig.  42)  of  the  axilla 
is  formed  by  the  pectoralis  major  with  its  sheath,  the  pectoral  fascia, 
and  the  pectoralis  minor  with  its  sheath,  the  clavipectoral  fascia.  From 
the  outer  border  of  the  pectoralis  minor,  where  the  two  layers  of  its 
sheath  reunite,  this  clavipectoral  fascia  extends  across  in  front  of  the 
axilla  as  a  triangular  sheet  to  become  continuous  with  the  sheath  of  the 
coracobrachialis.  The  lower  border  or  base  of  this  fascia  is  connected 
with  the  axillary  fascia  and  helps  to  hold  up  the  latter  and  preserve 
the  hollow  of  the  arm  pit. 

The  posterior  axillary  wall  (Fig.  43)  is  formed  by  the  subscapu- 
laris,  latis?<iinus  dorsi,  and  teres  major  muscles,  the  inner  wall  by  the 
U|)per  four  ribs  and  spaces,  covered  by  the  serratus  magnus  muscle. 
The  outer  wall,  so  narrow  as  almost  to  deserve  the  name  angle,  is 
fanned  by  the  humerus  covered  by  the  subscapularis  and  biceps  tendons 
and  the  coracobrachialis.  The  apex  corresponds  to  the  first  intercostal 
space  at  the  commencement  of  the  axillary  vessels  and  is  occupied  by 
these  vessels,  the  lymphatics  and  the  brachial  plexus. 

The  base,  re})resented  by  the  hollow  of  the  arm  pit,  is  formed  by  the 
skin,  subcutaneous  tissue  and  axillary  fascia  which  extend  between  the 
anterior  and  posterior  borders  and  are  continuous  with  similar  structures 
on  the  chest  wall  internallv  and  the  arm  externallv.      The  skin  of  the 


168  THE    UPPER   EXTREMITY. 

base  is  thin,  sensitive  and  easily  chafed  so  that  it  does  not  bear  the 
pressure  of  apparatus  well.  It  is  richly  provided  with  hairs,  sebaceous 
and  sweat  glands  and  these  glands  or  the  hair  follicles  are  the  starting 
point  of  the  small  superficial  abscesses  often  met  with  here.  These 
tend  to  open  through  the  skin,  being  separated  from  the  axilla  by  the 
strong  axillary  fascia.  The  latter  is  coiifhiuous  icifh  the  pectoral  and 
clavipectoral  fascia  in  front,  the  fascia  of  the  latissimus  dorsi  behind, 
the  sheath  of  the  axillary  vessels  and  the  deep  fascia  of  the  arm  exter- 
nally and  that  of  the  thorax,  covering  the  serratus  magnus  internally. 
It  effectually  (imifs  tJie  don-nward  spread  of  an  axillary  abscess  or 
hsematoma  as  do  the  other  walls  of  the  axilla  the  extension  in  their 
direction.  Hence  after  filling  the  axilla,  and  thereby  bulging  the 
anterior  wall,  thrusting  back  the  scapula  and  obliterating  the  hollow 
of  the  armpit,  an  ((.riUari/  abseess  or  hematoma  may  pass  up  along  the 
vessels  into  tlie  supraclavicular  fossa  and  the  neck.  An  ((/>sc<ss  may 
occur  behind  the  pectoralis  major,  between  it  and  the  pectoralis  minor 
and  clavipectoral  fascia.  Such  an  abscess  would  be  separated  from 
the  axilla  by  the  strong  clavipectoral  fascia  and  would  point  along  the 
lower  border  of  the  pectoralis  major,  or  possibly  in  the  sulcus  between 
it  and  the  deltoid. 

In  opening  an  axillary  abscess  the  incision  should  be  made  at  the 
center  of  the  base  or  floor  of  the  axilla,  midway  between  the  anterior 
and  posterior  folds,  so  as  to  avoid  the  subscapular  vessels  along  the 
lower  border  of  the  subscapularis  and  the  long  thoracic  along  the 
lower  border  of  the  pectoralis  minor.  It  should  be  nearer  the  thoracic 
or  inner  irall  than  the  outer  to  avoid  the  axillary  vessels  in  the  latter 
situation,  but  not  so  near  the  inner  wall  or  so  deeply  plunged  internally 
as  to  wound,  as  has  been  done,  the  long  thoracic  nerve,  which  lies  on  and 
supplies  the  serratus  magnus.  An  occasional  branch  from  the  axillary 
or  brachial  artery  crossing  beneath  the  skin  of  the  axilla  to  the  breast, 
in  place  of  or  accessory  to  the  long  thoracic,  is  sometimes  found,  espe- 
cially in  female  subjects,  and  might  be  injured  in  the  above  incision. 

The  contents  of  the  axilla  couxprise  the  axillary  vessels  and  their 
branches,  togetlier  with  nerves,  lymphatic  nodes  and  vessels,  areolar 
tissue  and  fat. 

The  axillary  artery  keeps  to  the  outer  angle  or  wall  of  the  axilla 
in  all  positions  of  the  arm,  forming  a  curve  convex  outward  and  up- 
ward when  tlie  arm  liangs  by  the  side  and  a  straight  line  from  a  little 
external  to  the  middle  of  the  clavicle  to  the  groove  on  the  inner  side 
of  the  biceps  when  the  arm  is  abducted  to  90°  and  rotated  outward. 
The  axillary  vein  lies  internal  to  and  somewhat  below  the  artery.  It 
overlaps  the  artery,  es[)ecially  during  expiration  and  in  its  upper  and 
lower  parts,  being  more  separated  from  it  in  the  middle  portion  as  it 
takes  less  of  a  curve  than  the  artery.  When  the  arm  is  abducted  the 
vein  is  drawn  over  the  artery  so  as  to  lie  almost  entirely  in  front  of  it 
and  conceal  it.  The  outer  vena  comes  of  the  brachial  artery  may  often 
be  found  passing  over  the  lower  part  of  the  axillary  artery  to  join  the 
vein  which  is  formed  by  the  union   of  the  inner  vena  comes  and   the 


PLATE    XVI  I 


BRACHIAL    PLEXUS 


FIG.   4.2. 

ANTERIOR 
THORACIC 
AXILLARY  NERVE 

ARTERY  \        ^"^ 


CEPHALIC         ACROMIO- 
VEI  N  THORACIC 

ARTERY 


Infraclavicular  fossa  after  removal  of  the  fasciae. 
The  pectoralis  niusele  is  separated  froni  the  clavicle 
and  turned  down.     (Zuckerkandl.) 


FIG.  43. 


LONG    THORA • 
CIC    ARTERY 


BASILIC 
VEIN 
BRACHIAL 
ARTERY    ~\<^ 


INTERCOSTO- 
HUMERAL    NERVE 


LONG    THORACiC 
NERVE 


SUBSCAP 
ARTERY 


Axilla  from  below   after'   removal   of  fasciae,   connective 
tissue   and    lymph-nodes.      The    pectoralis   major   is   raised 

up.     (Zuckerkandl.) 


THE  AXILLARY  LYMPH  NODES.  169 

basilic  vein.  This  uni(jn  usually  occurs  near  the  lower  border  of  the 
subscapularis  but  sometimes  not  until  just  below  the  clavicle,  a  C(jndi- 
tion  unfavorable  to  operations  on  the  artery  as  it  is  crossed  by  many 
branches  wiiich  unite  the  two  veins.  A  muscular  slip  from  the  latis- 
simus  dorsi  to  the  pectoralis  major  may  be  found  crossing  the  inner 
aspect  of  the  axillary  vessels  in  the  lower  part  of  their  course.  Tl)is 
may  be  mistaken  for  the  coracohrachialis  muscle,  which  is  the  fjuifle 
to  the  lower  part  of  the  axillary  artery.  The  latter  part  is  superficial 
and  easily  ligated,  remembering  that  the  vein  lies  to  its  inner  side, 
separated  from  it  by  the  internal  cutaneous  and  ulnar  nerves,  while 
the  musculocutaneous  nerve  is  external  and  the  median  nerve  in  front 
and  externally,  its  inner  root  crossing  in  front  of  the  artery.  The 
incision  is  behind  the  anterior  axilla  fold,  in  line  with  the  vessel  (see 
above)  which  lies  at  the  junction  of  the  anterior  and  middle  thirds  of  the 
axilla  and  is  separated  from  tlie  shoulder  joint  by  the  subscapular  and 
its  tendon,  and  from  the  humerus  by  the  coracobrachialis  and  the  ten- 
dons of  the  biceps.  The  axillary  vein  shows  the  respiratory  wave 
and  its  upper  part  is  held  open  by  its  adhesion  to  the  costocoracoid 
membrane.  Both  of  these  facts  increase  the  liability  of  the  entrance 
of  air  in  case  of  its  being  wounded.  The  vein  is  more  often  wounded 
than  the  artery,  as  it  is  larger,  more  superficial  and  overlies  it,  but 
in  injuries  by  traction,  as  in  reduction  of  a  dislocation,  the  artery  is 
more  often  injured  than  the  vein.  The  relative  frequency  of  aneurism 
of  the  axillary  artery  is  aUrihutable  to  its  nearness  to  the  heart,  its  ab- 
rupt curve,  its  extensive  and  frequent  movements,  and  its  liability  to 
share  in  the  many  lesions  of  the  upper  limb.  The  axillary  nerves  are 
seldom  torn  by  traction  and  not  often  injured  by  a  wound,  the  median 
being  involved  most  frequently,  the  musculospiral  least  frequently, 
owing  to  their  relative  depth. 

The  axillary  lymph  nodes  are  of  great  surr/ical  importance,  especially 
in  view  of  their  involvement  in  septic  infection  of  the  u])per  extremity 
and  cancerous  growths  of  the  breast.  They  comprise  t/iree  or  four 
fairly  distinct  groups;  the  axillary  nodes  proper  (3-4)  form  a  chniii 
along  the  vessels  and  receive  the  lymphatics  of  the  arm  ;  the  pectoral 
nodes  (4-5)  along  the  course  of  the  long  thoracic  artery  and  the  lower 
border  of  the  pectoralis  minor  and  on  the  serratus  niagnus  receive  the 
lymphatics  from  the  mamma,  the  front  side  of  the  chest  and  the  al)- 
doraen  above  the  umbilicus  ;  the  subscapular  noden  (2)  along  the  sul)- 
scapular  artery  receive  lymph  from  the  back  ;  the  subclavian  or  infr((- 
claricular  nodes  (2)  just  l)elow  the  clavicle  on  the  costocoracoid 
nienibrane  between  the  deltoid  and  great  pectoral  muscles,  receive 
lymph  from  the  outer  part  of  the  arm  and  the  deltoid  region.  Of 
these  the  most  important  are  the  first  and  second  groups  and  especially 
the  latter,  in  connection  with  cancer  of  the  breast.  As  they  lie  along 
tlie  inner  or  f/ioracic  ivall  (f  (he  axilla  it  is  tiiis  wall  that  should  be 
p(ilp(ded  to  determine  whetlier  there  is  lymphatic  involvement.  In 
persons  at  all  stout  I  have  found  it  difficult  or  impossible  to  palpate 
nodes  only  slightly  enlarged.     Belonging  to  this  group  are  one  or  two 


170  THE   UPPER  EXTREMITY. 

nodes  at  the  level  of  the  third  and  fourth  ribs  which  are  usually  the 
first  to  be  involved  in  cancer  of  the  breast. 

As  a  free  communication  exists  not  only  between  the  nodes  of  each 
group  but  between  the  different  groups,  infection  of  any  one  may 
extend  to  all  the  others.  Hence  in  removing  the  axillary  nodes  in  a 
case  of  cancer  of  the  breast  we  remove  not  the  pectoral  group  only  but 
all  the  groups  and  the  fatty  and  areolar  tissue  which  contains  lymph 
vessels.  As  the  axillary  nodes  communicate  with  the  deep  cervical 
and  the  one  or  two  in  the  supraclavicular  fossa,  we  should  examine 
these  in  advanced  cases  to  see  how  far  the  infection  has  spread.  Some 
operators  regularly  remove  any  in  the  subclavian  triangle  in  addition 
to  those  in  the  axilla.  The  entire  axilla,  up  to  its  apex  is  well  exposed 
in  HalsterVs  operation  in  which  the  sternal  portion  of  the  great  pectoral 
is  removed,  its  clavicular  portion  incised  vertically  and  the  pectoralis 
minor  divided.  The  nodes  when  cliseased  are  often  adherent  to  the 
axillary  vessels,  especially  the  vein,  and  their  pressure  on  the  latter 
causes  the  oedema  of  the  arm  often  observed  in  advanced  cases. 

Although  in  inflammatory  or  other  affections  of  the  arm  the  axillary 
group  of  nodes  are  usually  enlarged  and  painful  and  often  break  down 
into  an  abscess  so  as  to  require  removal  or  incision,  yet,  in  at  least  three 
cases  of  profound  sepsis  of  the  arm,  ending  fatally  after  a  time,  I 
found  no  swelling  or  tenderness  of  these  nodes  in  the  axilla.  But 
whether  this  was  due  to  an  imperfection  of  the  glands  or  to  the  nature 
of  the  infection  I  am  unable  to  say.  At  least,  having  observed  a  simi- 
lar condition  in  the  lower  extremity  in  two  fatal  cases  I  consider  the 
prognosis  bad  when  the  glands  of  the  axilla  or  groin  are  not  enlarged. 

THE  REGION  OF  THE  ARM  OR  UPPER  ARM. 

This  extends  from  the  lower  limit  of  the  "shoulder,"  the  insertion 
of  the  pectoralis  major  internally  and  the  deltoid  externally,  to  the 
upper  limit  of  the  region  of  the  elbow,  two  or  three  fingers'  breadths 
above  the  condyles. 

Surface  Markings  and  Landmarks. — Whereas  in  women,  infants 
and  fat  subjects  the  arm  is  regularly  rounded,  in  muscular  subjects  it  is 
flattened  on  each  side  and  especially  prominent  in  front,  owing  to  the 
distinctly  outlined  biceps  muscle.  On  either  side  of  the  latter  is  a  groove, 
of  which  the  inner  is  much  the  more  marked  and  runs  from  the  axilla 
to  the  bend  of  the  elbow.  It  indicates  the  position  of  the  basilic  vein 
and  the  brachial  artery,  the  course  of  the  latter,  in  the  extended  and  supi- 
nated  arm,  corresponding  to  a  line  drawn  along  the  inner  border  of  the 
biceps,  beneath  the  anterior  axillary  fold,  to  the  middle  of  the  bend 
of  the  elbow.  It  is  s^iperficial  and  can  be  felt  throughout  its  entire 
length.  The  outer  shallower  groove  extends  up  to  the  deltoid  insertion 
and  indicates  ih^  position  of  the  cephalic  vein,  which  above  the  deltoid 
insertion  runs  upward  and  inward  along  the  internal  border  of  that 
muscle  and  then  in  the  groove  between  it  and  the  pectoralis  major. 
The  deltoid  insertion  is  easily  made  out  and  is  an  important  landmark, 


THE  DEEP  FASCIA  OF  THE  ARM.  171 

indicating  the  middle  of  the  luiiiKiral  shaft  and  tlie  level  of  the  iii.ser- 
tion  of  the  coraeol)racliialis,  of  the  upper  limit  of  the  hraehialis  antieiis, 
of  the  entrance  of  the  nutrient  artery  on  the  inner  surface  and  of  the 
point  where  the  rausculospiral  nerve  and  superior  i)rofunda  artery 
reach  the  outer  border  of  the  bone.  The  .sliaft  of  the  liumerus  is  so  well 
covered  Ijy  muscles  that  it  can  only  be  felt  below  the  deltoid  insertion, 
from  whence  the  outer  border  can  be  traced  down  into  the  external 
supracondylar  ridoe. 

Superficial  Topography. — The  course  of  the  medioM  nerve  corre- 
si)()nds  to  tiiat  of  the  artery,  lying  external  to  it  in  the  upper  third, 
in  front  in  the  middle  third  and  internal  in  the  lower  third.  The 
internal  prof tuida  artery  is  represented  by  a  line  from  the  inner  aspect 
of  the  brachial  artery  at  the  middle  of  the  shaft  to  the  back  part  of 
the  internal  condyle.  The  ulnar  nerve,  following  the  brachial  artery 
on  its  inner  side,  diverges  from  it  at  the  middle  of  the  shaft  with  the 
inferior  profunda  and  follows  a  line  from  this  point  to  the  gap  between 
the  olecranon  and  the  internal  condyle.  It  may  be  felt  along  the  back 
of  the  internal  supracondylar  ridge.  The  musculosjiiral  nerve,  with 
the  superior  profunda  artery,  follows  a  line  from  just  below  the  poste- 
rior fold  of  the  axilla  downward,  backward  and  outward  to  the  outer 
border  at  the  deltoid  insertion  and  thence  downward  to  the  front  of 
the  external  condyle,  lying  between  the  brachioradialis  and  the  bra- 
chialis  anticus  in  the  lower  fourth  of  the  arm.  The  lower  end  of  the 
outer  bicipital  groove  corresponds  to  the  superficial  portion  of  the 
mnscidocataneous  nerve.  The  anastomotica  magna  is  given  oif  al^out 
two  inches  above  the  bend  of  the  elbow. 

The  skin  of  the  arm  is  smooth  and  thin,  especially  anteriorly  and 
laterally,  where  it  is  very  free  from  hairs,  so  that  it  is  here  very  suit- 
able for  skin  flaps  and  for  skin  grafting.  The  point  of  insertion  of 
the  deltoid  is  free  from  muscular  movement  so  that  the  overlvino;  skin 
is  very  suitable  for  vaccination,  as  it  was  formerly  for  the  application 
of  a  seton.  The  skin  is  so  loosely  attached  by  the  subcutaneous  tis- 
sues to  the  deep  fascia  that  in  circular  amputation  it  can  be  sufficiently 
drawn  up  by  the  traction  of  the  hand  and  requires  no  separate  dissec- 
tion to  form  a  flap.  If  it  requires  any  separation  with  the  knife  it  is 
only  along  the  lines  of  the  intermuscular  septa.  It  is  more  loosely  at- 
tached on  the  inner  than  on  the  outer  aspect  of  the  arm  (/.  e.,  over  the 
deltoid).  The  skin  is  stripj)ed  up  etiually  readily  in  contused  and 
lacerated  wounds. 

The  deep  fascia  {lyrachial  aponeurosis)  completely  invests  the  under- 
lying muscles  to  which  it  is  loosely  attached.  It  is  continuous  with 
that  covering  the  elbow  region  below  and  with  the  fascia  of  the  deltoid, 
the  axilla  and  its  anterior  and  posterior  walls  above.  It  is  thin  in  front, 
where  it  covers  the  bicejis,  thicker  behind.  At  the  sides  it  is  con- 
nected by  the  internal  and  external  intermuscular  septa  with  the  internal 
and  external  borders  of  the  bone.  The  crtvrnfd  infcrttuiscnlar  srj)furn, 
the  weaker  of  the  two,  crtrmls  from  the  external  condyle  to  the  deltoid 
insertion  and  is  perforated  by  the  musculospiral  nerve  and  superior  ]iro- 


172  THE   UPPER  EXTREMITY. 

funda  artery  about  midway  between  the  deltoid  insertion  and  the  tip 
of  the  external  condyle.  The  internal  intermuscular  septum  extends 
from  the  internal  condyle  to  the  teres  major  muscle  (internal  bicipital 
region)  and  is  perforated  by  the  ulnar  nerve  and  the  inferior  profunda 
artery  about  two  inches  above  the  internal  condyle. 

These  two  septa  with  the  deep  fascia  divide  the  arm  into  two 
compartments  of  which  the  posterior  contains  the  triceps  muscle  with 
the  upper  part  of  the  musculospiral  and  the  lower  brachial  portion  of 
the  ulnar  nerves  and  their  accompanying  vessels,  the  anterior  contains 
the  rest  of  the  brachial  muscles  and  soft  parts.  These  compartments 
confine  to  a  certain  extent  inflammatory  or  hemorrhagic  effusions 
which  however  can  pass  from  one  to  the  other  by  foUowiug  the 
structures  that  pierce  them.  The  brachicd  aponeurosis  itself  is  pierced 
along  the  internal  bicipital  groove  by  the  internal  cutaneous  nerve 
about  the  middle  and  by  the  basilic  vein  a  little  below  the  middle  of 
the  arm ;  and  along  the  external  bicipital  groove  by  the  external 
cutaneous  nerve,  just  above  the  elbow. 

The  brachial  artery  may  be  ligated  in  any  part  of  its  course.  The 
best  guide  is  the  inner  border  of  the  biceps  which  may  overlap  it  in 
muscular  subjects.  Its  changing  relations  with  the  median  nerve  (see 
above)  should  be  remembered,  but  these  are  not  always  constant,  so  that 
this  nerve  is  a  poor  guide.  The  number  of  cross  branches  between 
the  two  vente  comites  sometimes  embarrasses  the  operator.  The  idnar 
nerve  lies  close  to  the  inner  side  in  its  upper  half  and  may  be  mistaken 
for  the  median  if  the  incision  is  too  far  internal.  The  musculospiral 
nerve  is  also  behind  the  upper  end  of  the  vessel. 

Anomalies  occur  more  often  in  the  brachial  than  in  almost  any  other 
artery.  The  most  important  anomedy  from  a  surgical  standpoint  is  its 
high  division  (even  iu  the  axilla)  in  which  case  the  smaller  branch  lies 
in  front,  the  other  behind  the  median  nerve.  Hence  if  an  artery  is 
found  in  front  of  the  nerve  we  should  look  for  another  behind  it. 
Again  in  the  lower  part  of  the  arm  the  artery  or  one  of  its  branches 
may  deviate  internally  to  pass  to  the  inner  side  of  the  supracondylar 
process  with  the  median  nerve.  Behind  the  artery  lies  the  coraco- 
brachialis  for  a  short  distance,  lower  down  the  brachialis  anticus.  The 
artery  lies  internal  to  the  humerus  in  its  upper  half  or  more,  in  front 
of  it  below ;  so  that  it  may  he  compressed  against  the  bone  by  pressure 
outward  and  slightly  backward  above,  and  directly  backward  below. 
Unless  this  pressure  is  applied  carefully  l)y  the  fingers  the  median 
nerve  can  hardly  avoid  pressure,  the  result  of  which  is  the  pain  oft(>n 
complained  of  after  the  ap])lication  of  a  tourniquet. 

The  lymph  vessels  are  largely  superficial.  Most  of  these  15—18 
accompany  the  basilic  vein  where  they  can  readily  be  seen  as  a  band 
of  red  striie  in  lymphangitis.  A  lymph  vessel  usually  accompanies 
the  cephalic  vein. 

The  musculospiral  nerve  in  its  passage  along  the  musculospiral  groove 
is  in  close  contact  with  the  bone  and  hence  may  be  injured  in  con- 
tusions and  wounds  and  especially  in  fractures  of  the  humeral  shaft.    It 


FRACTURE  OF  THE  SHAFT  OF  THE  HUMERUS.  173 

may  also  escape  injury  at  the  time  of  fracture  to  be  subsequently 
involved  and  conipresucd  in  the  callus.  In  many  cases  an  o])eration 
has  become  necessary  to  free  it  from  the  canal  of  callus  or  bone  in 
which  it  is  compressed.  It  has  also  been  paralyzed  by  the  pressure  of 
the  head  restin<r  upon  the  supinated  and  abducted  arm  in  sleep.  In 
its  upper  part,  on  the  inner  aspect  of  the  arm,  it  is  the  nerve  which 
most  often  suffers  from  crutch  jxiralysis,  the  ulnar  coming  next  in  fre- 
quency. In  all  such  cases,  besides  pain  along  the  course  and  in  the 
branches  of  the  nerve,  the  symptoms  of  paralysis  resemble  those  in 
lead-palsy,  which  also  affects  this  nerve.  The  extensors  of  the  wrist 
and  fingers  are  paralyzed  and  "  icfid-drop"  is  produced,  indicating  the 
inability  of  tlie  extensors  to  extend  the  wrist. 

The  iicrre  is  most  conveniently  exposed  after  it  has  pierced  the  inter- 
muscular septum  hij  an  incisio)i,  following  the  anterior  border  of  the 
brachioradialis,  whose  center  is  opposite  the  point  of  perforation  of 
the  septum  or  midway  between  the  deltoid  insertion  and  the  external 
condyle.  It  is  sought  for  as  it  enters  the  gap  between  the  brachio- 
radialis and  the  brachialis  anticus.  If  it  is  to  be  exposed  on  account 
of  injury  in  the  rausculospiral  groove  the  incision  is  carried  along  the 
posterior  margin  of  the  deltoid  insertion. 

Fracture  of  the  shaft  of  the  humerus,  or  that  part  between  the 
insertion  of  the  pectoralis  major  and  the  upper  part  of  the  supracon- 
dylar ridges,  is  most  often  due  to  direct  violence,  sometimes  to  indirect 
violence.  It  is  more  often  broken  by  muscular  action,  such  as  throw- 
ing a  stone  or  the  trial  of  strength  known  as  "  wrist  turning,"  than  any 
otheV  bone  in  the  body.  The  displacement  is  usually  inconsiderable 
and  depends  largely  upon  the  fracturing  force.  Secondarily  the 
muscles  attached  to  the  two  fragments  may  have  some  effect  upon  their 
relative  position.  Thus  the  lower  fragment  is  often  drawn  up  by  the 
biceps  and  triceps  muscles,  but  the  weight  of  the  arm  resists  any  con- 
siderable shortening.  Theoretically  in  fractures  above  or  below  the 
deltoid  insertion  the  lower  or  uj)pcr  fragments  respectively  would  be 
drawn  outward  by  the  action  of  the  deltoid  but  jiractically  the  dis- 
placement is  usually  independent  of  this  action. 

Delayed  union  and  non-union  are  of  much  more  frequent  occurrence 
in  the  humerus  than  in  any  other  bone.  Among  the  caunex  that  lead  to 
this  may  be  mentioned,  (1)  the  interposition  between  the  fragments  of 
mucular  tissue  with  which  the  bone  is  almost  conii>letely  surrounded, 
the  two  fragments  being  driven  into  muscular  masses  on  opposite  sides 
of  the  bone  ;  (2)  the  defective  imnioJiilizafion  of  the  fragments  due 
largely  to  the  im])crfect  fixation  of  the  joints  above  and  below.  Ac- 
cording to  Hamilton  the  flexed  elbow  soon  becomes  stiff  by  reason  of 
muscular  rigidity  so  that  the  movement  of  the  forearm  in  flexion  and 
extension  of  the  elbow  imparts  a  horizontal  or  lateral  movement  to 
the  upper  end  of  the  lower  fragment.  ]5ut  this  alone  cannot  account 
for  the  condition  for  it  would  cause  a  greater  movement  of  the  frag- 
ments of  fractures  high  up  in  the  shaft  and  non-union  is  more  common 
in  the  middle  third. 


174  THE   UPPER  EXTREMITY. 

Amputation  of  the  Arm. — ///  the  lower  half  the  circular  amputation 
is  best.  The  division  and  retraction  of  the  skin  has  been  ah-eady 
referred  to.  As  only  the  biceps  has  no  attachment  to  the  bone  it 
retracts  most  and  requires  separate  division  a  thumb's  breadth  below 
where  the  other  muscles  are  divided,  at  the  edge  of  the  retracted  skin. 
After  division  of  the  muscles  and  continued  retraction  of  the  soft  parts 
the  fleshy  cone  may  again  be  divided  at  its  base,  at  the  level  of  the 
fully  retracted  skin. 

Above  the  middle  of  the  arm  the  biceps,  long  head  of  the  triceps, 
deltoid  and  coracobrachialis  may  all  retract  considerably  and  unequally, 
hence  amputation  by  long  anterior  and  shorter  (one  half  of  anterior) 
posterior  flaps  has  some  advantages.  The  brachial  artery  should  be  in 
the  posterior  flap.  The  principal  arteries  cut  are  the  brachial  (with  the 
median  nerve),  the  superior  profunda  on  the  postero-external  aspect  (with 
the  musculospiral  nerve)  and  in  the  lower  half  of  the  arm  the  inferior 
profunda  on  the  inner  aspect  (with  the  ulnar  nerve).  (Fig.  44.)  In  the 
flap  method  all  the  principal  arteries  divided  are  in  the  posterior  flap. 

To  reach  the  humerus  for  removal  of  sequestra,  etc.,  incision  along 
the  outer  border  is  jn-eferable,  for  the  musculospiral  nerve  is  the  only 
structure  which  need  be  avoided. 

THE  REGION  OF  THE  ELBOW. 

The  limits  of  this  region  may  be  arbitrarily  assigned  as  two  or  three 
fingers'  breadths  above  and  below  the  "  fold  of  the  elbow."  The  elbow 
sflatfcncd  from  before  backward. 

Surface  Markings  and  Landmarks.  (Fig.  45.) — In.  front  are 
visible  three  iniisrular  elevations,  one  on  the  outer  side  corresponding  to 
the  brachioradialis  and  the  extensor  group,  one  on  the  inner  side  corre- 
sponding to  the  pronator  radii  teres  and  the  flexor  group,  and  one  in 
the  center  corresponding  to  the  biceps.  The  two  lateral  elevations  con- 
verge and  meet  below,  enclosing  between  them  a  depression,  the  cubital 
fossa,  into  which  the  biceps  tendon  is  felt  to  sink  toward  its  insertion. 
From  this  fossa  tieo  grooves  forming  a  V  are  continued  upward  along  the 
two  sides  of  the  bicepst  endon,  to  become  continuous  with  the  bicipital 
grooves  of  the  arm.  The  details  are  distinct  only  in  thin  or  muscular 
subjects.  The  biceps  tendon  is  plainly  felt,  especially  along  its  outer 
border,  the  inner  border  being  covered  by  the  bicipital  fascia.  The 
''fold  of  the  elboK^  is  a  transverse  crease  in  the  skin  of  the  front  of 
the  elbow  extending  transversely,  with  a  slight  convexity  downward, 
between  the  two  condyles.  Hence  it  is  some  little  ways,  2-4  cm., 
above  the  joint  line.  It  is  obliterated  in  extension  and  not  constant  in 
position  so  that  it  is  not  of  great  service  as  a  landmark.  It  may  be  of 
some  use,  as  employed  by  Malgaine,  to  diagnose  between  an  ordinary 
dislocation  of  the  elbow  and  a  supracondylar  fracture  of  the  humerus, 
the  lower  end  of  the  humerus  projecting  below  this  fold  in  the  former 
and  the  lower  end  of  the  upper  fragment  forming  a  prominence  above 
it  in  the  latter. 


PLATE    XVIII 


FIG.    A^ 


CEPHALIC 
VEIN 


MOSCULO-SPIRAL 


BRACHIALIS 

MUSCLE  BICEPS 

MUSCLE 

■  ^       (-   ■      y  MUSCULO-CUTA- 

—  <--^,^         -  /    '  ^/     NEOUS    NERVE 

'vT  ^^'^'^7-^t 


BRACHIAL 
APONEUROSIS 


EXT.   INTERMUS- 
CULAR   SEPTUM 


TRICEPS 
MUSCLi 


BRACHIAL 
/ARTERY 

,M  E  O I  A  N 

/^  NERVE 
^^^  _BASI  Lie 
^^  VEIN 


-JLNAR    NERVE 


I  NT.    INTERMUS- 
CULAR   SEPTUM 


Cross  section  through  the  niiddle  of  the  right  arm  of  a  female. 
Upper  segment  viewed  froni  below.     (Tillaux.) 


FIG.    43. 


NTERNAL 
CUTANEOUS 
NERVE 


BRACHIAL 
ARTERY 


CEPHALIC 
VEIN 


EXTERNAL 
CUTANEOUS 
NERVE    AND 
MEDIAN    VEIN 


MEDIAN 
BASILIC 
VEIN 


Front  of  right  elbow;   superficial  view.     (Joessel.) 


TOPOGRAPHY  OF  THE  ELBOW.  175 

The  two  condyles  are  plainly  felt,  the  inner  and  more  prominent  one 
even  in  conditions  of  extreme  swelling.  About  2  era.  below  the 
more  rounded  external  condyle  the  rounded  Itcad  of  tlic  radian  can  Ije 
felt,  especially  on  rotating  the  forearm.  In  extension  of  the  elbow  a 
marked  depression  indicates  the  position  of  the  head  of  the  radius 
and  corresponds  to  the  interval  between  the  brachioradialis  and  the 
anconeus  muscles.  The  two  humeral  coikUjIch  are  //;  the  same  trans- 
verse line  with  one  another  and,  when  the  arm  is  extended,  with  tlie  tip 
of  the  plainly  felt  olecranon  proceHn.  When  the  elbow  is  flexed  the  tip 
of  the  olecranon  comes  to  lie  below  the  intercondylar  line.  Thet^e 
relations  are  of  great  importance  in  differentiating  dislocation  from 
supracondyloid  fracture,  for  in  the  latter  case  they  are  preserved,  in  the 
former  they  are  altered.  Furthermore  in  full  extension  the  point  of 
the  olecranon  is  nearly  in  the  same  transverse  vertical  plane  with  the 
two  condyles,  while  in  dislocation  it  is  displaced  backward.  The  ole- 
cranon does  not  lie  midway  between  the  two  condyles  but  nearer  the 
internal  condyle,  by  12  to  15  mm.,  so  that  the  groove  between  the  ole- 
cranon and  the  inner  condyle  is  narrower  as  well  as  deeper  than  that 
between  the  olecranon  and  the  outer  condyle.  Neither  the  coronoid 
process  or  tlie  radial  tubercle  can  be  distinctly  felt  in  ordinary  subjects. 

Topography. — The  joint  line  of  the  elbow  is  only  about  two  thirds 
(4  cm.)  of  the  width  between  the  condyles  and,  while  it  nearly  cor- 
responds externally  with  the  lateral  limit  of  the  condyle,  its  inner  end 
is  some  distance  (nearly  2  cm.)  external  to  the  internal  condvle.  This 
partly  accounts  for  the  prominence  of  the  internal  condyle.  The  line 
of  tlie  humeroradial  joint  is  horizontal  and  can  be  felt  between  the  hciid 
of  the  radius  and  the  external  condyle,  that  of  the  kumeroulnar  joint 
slopes  obliquely  downward  and  iuAvard  so  that  the  inner  end  of  the 
trochlea  is  1  cm.  below  the  outer  end.  The  obliquity  of  the  humero- 
ulnar  joint  makes  the  axis-  of  the  extended  forearm  to  diverge  outward 
at  an  angle  of  6°,  accounting  for  the  "carrying  function."  It  also 
makes  the  hand  to  be  carried  up  toward  the  face  in  flexion,  unless  the 
forearm  is  supinated. 

The  ulnar  nerve,  lying  in  the  deep  and  narrow  depression  between 
the  olecranon  and  the  internal  condyle,  is  exposed  to  injury  by  pressure 
against  its  hard  bed.  Pressure  on  it  gives  the  peculiar  numbness  and 
tingling  of  the  ulnar  side  of  the  hand,  etc.,  and  is  known  as  hitting 
the  "  funny  bone."  It  was  wittily  remarked  that  it  was  so  named 
because  it  bordered  on  the  humerus.  The  nerve  may  lie  in  h'out  of 
the  internal  condyle  or  slip  in  front  on  flexion  of  the  elbow  (Qnain). 
It  is  particularly  imjwrtant  to  avoid  if  in  exri.^io}i  of  the  elbow  by 
keeping  close  to  the  bone  in  its  neigliborhood.  In  a  case  of  anchylosis 
of  the  elbow  with  much  overgrowtii  of  bone,  due  to  a  bad  fracture,  I 
have  found  the  nerve  in  a  bony  canal. 

The  brachial  artery  lies  in  the  inner  of  the  two  grooves  in  front  of 
the  elbow,  just  internal  to  the  pearly  white  biceps  tendon,  which  is  an 
excelk'nt  guide  to  it,  and  rather  more  external  to  the  median  nerve.  It 
passes  under  the  hicipitid  fascia  where  it  hifureatcs  about   half  an  inch 


176  THE   UPPER  EXTREMITY. 

below  the  center  of  the  bend  of  the  elbow.  It  may  be  compressed  by  for- 
cible flexion  of  the  joint  so  as  to  diminish  or  even  stop  the  radial  pulse. 
Accordingly  (incari^m)<  here,  more  frequent  in  blood-letting  days,  have 
been  treated  by  compression,  by  flexion  of  the  elbow.  In  tiie  fully 
extended  position  the  artery  is  somewhat  flattened  beneath  the  bicipital 
fascia  so  as  to  lessen  the  radial  pulse,  or  even  to  stop  it  in  the  hyper- 
extension  possible  with  fracture  of  the  olecranon  or  dislocation  of  the 
elbow.  It  has  been  ruptured  by  the  forcible  straightening  of  a  stiif, 
bent  elbow. 

The  median  vein  is  joined  by  the  deep  median  vein  and  divides  into 
the  median  basilic  and  median  cephalic  in  the  depression  at  the  apex 
of  the  V  (e«6/^«/ /o.sscf).  The  median  haxUie  vein  cro.s'.s'/?ir/ superficial 
to  the  biceps  tendon  and  fascia  comes  to  lie  in  the  inner  groove  where 
it  joins  the  posterior  ulnar  vein  a  little  above  the  internal  condyle, 
forming  thereby  the  basilic  vein.  Similarly  the  median  cephalic,  pass- 
ing  up  in  the  outer  groove,  forms  the  cephalic  vein  by  joining  the 
radial  vein  about  the  level  of  the  external  condyle. 

An  M-shaped  figure  is  thus  formed  by  the  veins  in  front  of  the 
elbow,  but  this  typical  arrangement  is  by  no  means  constant,  occurring 
only  in  about  50  per  cent,  of  cases.  But  in  almost  all  cases  a  com- 
municating vein  crosses  the  biceps  tendon  and  fascia  obliquely,  and 
therefore  overlies  the  brachial  artery,  and  this  vein  is  usually  large 
enougli  for  venesection  or  intravenous  infusion. 

The  median  basilic  vein  or  its  substitute  may  cross  the  artery  trans- 
versely or  obliquely  or  it  may  run  nearly  parallel  with  it,  in  front  of  it 
or  to  one  side.  Of  all  the  veins  in  front  of  the  elbow  the  median  basilic 
is  usually  the  largest,  the  most  prominent,  the  nearest  the  surface  and 
the  one  least  subject  to  variation.  Hence  it  was  the  one  most  often 
chosen  for  venesection  in  blood-letting  days,  and  now  is  often  chosen 
for  intravenous  infusion,  in  spite  of  the  fact  that  it  is  separated  from 
the  artery  beneath  by  the  bicipital  fascia  only.  This  membrane,  whose 
density  depends  upon  the  muscular  development,  is  an  excellent  pro- 
tection to  the  artery,  but  on  account  of  the  blind  method  of  venesection 
formerly  employed  it  is  not  strange  that  the  artery  was  often  wounded, 
giving  rise  to  aneurism  or  arteriovenous  aneurism,  the  latter  being 
more  common  at  the  elbow  than  anywhere  else.  The  median  cepJialic 
is  therefore  safer,  but  with  open  exposure  of  the  vein,  as  for  intra- 
venous infusion,  it  seems  scarcely  possible  to  wound  the  artery. 

Of  the  cnfaneoHs  )u'rres  at  the  elbow  the  e.vtenad  cutaneous  passes 
l)eliind  the  median  cephalic  vein,  the  anterior  division  of  the  internal 
cutaneous  passes  behind  or  (less  frequently)  in  front  of  the  median 
basilic.  Hence  the  latter  nerve  or  its  branches  may  be  wounded  in 
opening  the  median  basilic  vein,  an  injury  that,  according  to  Tillaux, 
may  lead  to  intense  and  chronic  neuralgia.  Small  twigs  of  the  external 
cutaneous  nerve  may  cross  in  front  of  the  median  cephalic  and  the 
injury  to  these  branches,  or  ])ossibly  the  main  trunk  behind  the  vein, 
and  their  inclusion  in  the  scar  may  lead,  according  to  Mr.  Hilton,  to 
a  reflex  contraction  of  the  elbow,  due  to  the  contraction  of  the  biceps 


THE  ELBOW  JOIST.  177 

and  brachialis  muscles  which  are  supplied  by  it.  He  has  cured  the 
condition  by  resection  of  the  scar  which  was  found  to  have  included 
some  of  the  nerve  filaments. 

The  HUperfic'ud  lyiajjhatics  accompanying  the  veins,  lying  in  front  of 
them,  and  are  most  numerous  on  the  antero-internal  aspect  of  the 
elbow.  Situated  in  front  of  the  intermuscular  septum,  an  inch  above 
the  internal  condyle,  is  the  cpifrcjc/i/cdr  lymph  uodc  (sometimes  two 
nodes),  the  lowest  node  in  the  upper  limb.  It  may  become  inflamed 
in  any  injury  or  inflammation  of  the  ulnar  side  of  the  hand  and  fore- 
arm and  the  inner  two  or  three  fingers,  from  whence  it  receives  lymph 
vessels.  Around  the  elbow-joint  is  an  cvfcnsive  and  free  a na.stomosis 
between  branches  of  the  superior  and  inferior  profunda  and  the  anas- 
tomotica  magna,  from  the  brachial  above,  and  branches  of  the  anterior 
and  posterior  ulnar,  posterior  interosseous  and  radial  recurrent  from 
the  ulnar,  interosseous  and  radial  arteries  below.  This  anastomosis 
provides  a  codtdercd  oirrahdion  in  case  of  ligature  of  the  brachial  or 
in  aneurism  at  the  elbow. 

The  skin  about  the  elbow  is  thin  and  fine  in  front,  where  it  is  readily 
excoriated  by  tight  bandages  or  poorly  applied  splints ;  it  is  thicker 
and  less  sensitive  behind.  Although  the  thin  skin  in  front  allows  the 
veins  to  be  clearly  seen  through  it,  yet  in  subjects  with  much  subcu- 
taneous fat  it  may  be  difficult  or  impossible  to  see  them.  Between  the 
skin  and  the  olecranon  is  a  mhcidancouH  bursa,  not  infrequently  the  seat 
of  a  bui-sdi.s  with  the  accumulation  of  serum  or  of  pus.  Occupations 
involving  pressure  on  the  elbow  favor  bursitis  here,  of  which  "  miners 
elbow"  is  an  example. 

The  elbow  joint  depends  for  its:  strength  largely  ujjon  the  shape  and 
relation  of  the  bones  forming  it,  reinforced  by  the  overlying  muscles 
and  the  lateral  ligaments.  Only  flexion  and  extension  are  permitted ; 
the  presence  of  hderal  motion  shows  that  the  ligaments  are  torn  or 
stretched  as  in  dislocation  or  tubercular  disease  and  hence  is  a  sign  of 
some  lemon  of  the  joint.  The  internal  lateral  is  the  strongest  and  most 
important  ligament  of  the  elbow  and,  as  it  resists  lateral  strain  as  well 
as  limits  flexion  and  extension,  it  suffers  most  often  from  sprains  and 
dislocations.  Its  attachment  to  the  entire  inner  border  of  the  great 
sigmoid  cavity  of  the  ulna  prevents  the  wide  separation  of  the  frag- 
ments in  fracture  of  the  olecranon  for  part  of  it  is  attached  above 
and  part  below  the  line  of  fracture.  The  anterior  and  posterior  parts 
of  the  capsule  are  the  weakest,  especially  the  posterior  portion  which 
presents  two  pouches,  one  on  either  side  of  the  olecranon.  As  this  is 
also  the  most  superficial  part  of  the  joint  the  effusion  in  joint  disease 
is  first  noticed  as  a  fiurtiading  su-el/in(/  here.  The  line  of  the  radio- 
humer(d  joint  also  shows  some  swelling  at  an  early  stage  and  here,  or  in 
the  pouches  on  the  sides  of  the  olecranon,  especially  the  external  one, 
the  joint  may  be  aspirated  or  injected.  Beneath  the  brachialis  a  dcey>- 
seated  bulging  of  the  thin  anterior  part  of  the  capsule  is  also  observed 
in  cITusion  into  the  joint.  Normally  tiie  joint  surfaces  are  in  contact 
in  all  positions,  but  if  the  soft  parts  are  divided  the  radius  and  humerus 
12 


178  THE   UPPER  EXTREMITY. 

separate  by  a  slight  interval  when  the  capsule  is  incised,  readily  allow- 
ing the  knife  to  enter  the  joint  in  exarticulation. 

In  case  of  suppuration  in  the  joint  the  capsule  is  (il:ch/  to  r/ive  loay 
at  its  weakest  point,  pjostero-superiorh/.  The  pus  thus  comes  to  lie 
between  the  triceps  and  the  humerus,  burrows  between  them  and  points 
at  either  border  of  the  muscle.  In  other  cases  it  may  perforate  the 
thin  anterior  ligament  beneath  the  brachialis  and  point  near  the  inser- 
tion of  the  latter. 

The  diseased  elbow  is  usually  held  in  a  position  of  seiaiHexion,  a 
position  assumed  when  the  joint  is  forcibly  injected  (Braune),  for  in 
this  position  it  holds  the  most  fluid.  In  disease  however  the  position 
is  probably  due  to  a  reflex  contraction  of  the  biceps  and  brachialis  mus- 
cles, supplied  by  the  musculocutaneous,  which  is  the  principal  nerve 
of  the  joint.  Owing  partly  to  the  accurate  coaptation  of  the  ulna  and 
humerus  anchylosis  of  the  elbow  after  injury,  disease  or  even  disuse  in 
a  fixed  position  is  not  uncommon.  Sudden  forcible  straightening  of 
an  anchylosed  elbow  entails  some  danger  of  rupture  of  the  brachial 
artery  at  the  bend  of  the  elbow.  If  the  elbow  is  anchylosed  in  a 
straight  or  semi-flexed  position,  the  anchylosis  should  be  broken  up  or 
the  elbow  excised,  for  in  this  position  the  arm  is  not  only  useless  but 
in  the  way. 

In  excision  of  the  elbow  joint  the  three  most  important  muscles  in  re- 
lation to  it,  which  act  on  it  and  therefore  must  be  preserved,  are  the 
biceps,  brachialis  and  triceps.  The  insertions  of  the  first  two  are 
readily  preserved.  The  ulna  may  be  divided  low  enough  to  remove 
the  entire  coronoid  process  without  sacrificing  the  insertion  of  the 
brachialis  into  the  tuberosity  at  its  lower  end.  The  usual  and  best 
incision  is  a  longitudinal  one  through  the  triceps  which  is  then  separated 
from  the  ulna  on  either  side  of  the  incision  by  longitudinal  cuts  close  to 
the  bone  (subperiosteally)  in  order,  as  far  as  possible,  to  leave  the  tri- 
ceps insertion  in  connection  with  the  periosteum  of  the  hone  below  the 
point  of  section.  The  strong  expansion  from  the  outer  margin  of  the 
triceps  tendon  should  always  be  saved  as  it  enables  the  triceps  to  retain 
a  hold  on  the  forearm.  In  freeing  the  parts  about  the  internal  condyle 
great  care  should  be  taken  to  avoid  injury  to  the  ulnar  nerve  lying  be- 
hind it,  by  making  whatever  incisions  are  necessary  close  to  bone  and 
longitudinal.  The  nerve  should  not  be  seen.  Another  nerve  in  some 
danger  of  injury  when  the  upper  end  of  the  radius  is  being  bared  is 
the  posterior  interosseous  as  it  winds  around  the  radius  in  the  supina- 
tor muscle.  It  is  wise  to  remove  two  inches  of  bone  (including  both 
humerus  and  forearm  bones)  to  avoid  the  danger  of  re-anchylosis. 

In  connection  with  excision  in  young  subjects  under  17  (when  the 
humeral  epiphyseal  line  ossifies)  it  may  be  noted  that  the  principal 
growtJi  in  length  of  the  humerus  occurs  at  the  upj)er  end. 

Dislocation  of  the  elbow  is  more  common  than  that  of  any  single 
joint  save  the  shoulder.  It  is  most  common  (85  per  cent.)  //(  the  first 
tiventy  years  of  life  when,  according  to  Kronlein,  it  is  the  equivalent 
injury  of  dislocation  of  the  shoulder  by  indirect  violence. 


SYMPTOMS  AND  SIGNS  OF  ELBOW  DISLOCATIONS.  179 

Dislocation  of  both  bones  of  the  forearm  backward  is  the  (i/jjicti/  j'oniiy 
being  by  far  the  most  euinmon.  It  is  usually  due  to  a  fall  on  the  out- 
stretehed  hand  by  which  the  elbow  is  hyjjciextended  and  often  a/xlucted. 
It  is  only  in  hyperextension  that  the  beak  of  the  olecranon  presses 
against  the  bottom  of  the  olecranon  fossa.  It  then  serves  as  a  fulcrum 
so  that  by  continued  hyperextension  the  ulna  is  torn  as  it  were  from 
the  humerus.  The  internal  lateral  ligament  is  thereby  torn,  usually 
at  its  insertion  into  the  humerus,  the  external  lateral  ligament  is  usu- 
ally torn  or  detached  from  the  humerus  and  the  rent  extends  across  the 
thin  anterior  ligament.  These  lateral  ligaments  oppose  hyperextension 
and  lateral  motion  and  are  the  strongest  bonds  holding  the  l)ones 
together.  Hence  when  they  are  torn  the  violence  continuing  forces 
the  coronoid  process  far  enough  backw-ard  to  be  pushed  up  behind  and 
above  the  trochlear  surface,  opposite  to  or  into  the  olecranon  fossa. 

Associated  Injuries. — The  orhicu/ar  Ufjainent  is  rarely  injured  and  a 
partial  preservation  of  the  external  lateral  ligament  may  affect  the  atti- 
tude of  the  limb,  adducting  it,  and  render  reduction  difficult.  The 
hrach'ialis  is  stretched,  sometimes  lacerated  and  rarely  torn  across.  The 
biceps  is  rendered  tense  and  occasionally  slips  around  the  outer  condyle. 
The  median  and  ulnar  nerves  may  be  greatly  stretched.  The  tip  of  the 
internal  condyle  is  often  torn  off  and  may  be  displaced  upward  with  the 
internal  lateral  ligament.  A  common  lesion  of  practical  importance  is 
the  .stripping  up  of  the  periosteum  at  the  hack  of  the  external  condyle. 
If  the  dislocation  remains  long  unreduced  new  bone  is  here  produced 
which  interferes  with  the  extension  of  the  elbow  by  impinging  on  the 
radius.  As  complications  there  may  he  fracture  of  the  coronoid  process, 
olecranon,  head  of  the  radius  (partial  or  complete)  and  the  shaft  or 
lower  extremity  of  the  radius. 

Symptoms  and  Signs. —  The  crucial  signs,  on  which  alone  the  diag- 
nosis should  rest,  are  the  relative  positions  of  the  two  condyles,  the 
olecranon  and  the  head  of  the  radius,  as  determined  by  })alpation. 
The  olecranon  is  displaced  backward  and  upward,  the  backward  dis- 
placement being  more  marked  in  flexion,  the  upward  in  extension. 
The  head  of  the  radius  can  he  felt  and  perhaps  even  seen  under  the  skin 
behind  the  external  condyle  and  to  the  outer  side  of  the  olecranon. 
In  addition  the  elbow  is  usually  flexed  at  an  angle  of  about  135°  but 
may  be  extended  or  even  hyperextended,  the  lower  end  of  the  humerus 
causes  a  fullness  in  front  (below  the  crease  of  the  elbow),  the  forearm 
appears  -shortened  in  front  and  broadened  above,  its  axis  may  be  devi- 
ated to  either  side,  flexion  and  extension  are  limited  and  painful  and 
latcnd  motion  exists. 

Reduction  is  often  accomplished  by  flexion  and  traction,  using  the 
knee  in  the  bend  of  the  elbow  as  a  fulcrum  and  to  produce  traction. 
In  this  method  the  coronoid  process  has  to  pass  down  behind  and  then 
below  the  trochlea  and  to  do  this  the  ulna  must  be  separated  from  the 
humerus  by  more  than  half  an  inch,  the  height  of  the  coronoid  process. 
This  can  only  occur  when  the  laceration  of  the  ligaments  and  soft 
parts  is  extensive  or,  as  often  happens,  is  made  so  by  the  process  of 


180  THE   UPPER  EXTREMITY. 

reduction.  It  also  requires  simultaneous  elongation  of  the  mus- 
cles of  the  front  and  back  of  the  arm.  Forcible  pronation  may  facili- 
tate it. 

A  method  more  in  line  with  the  principle  that  a  dislocated  bone 
should  be  returned  along  the  route  by  which  it  was  displaced  with  the 
least  possible  additional  rupture  of  the  soft  parts,  is  the  method  by 
traction  upon  the  extended  or  hyperextended  forearm  ;  followed  by 
flexion  of  the  elbow  or  by  direct  pressure  forward  on  the  upper  ends 
of  the  radius  and  ulna  and  backward  pressure  on  the  lower  end  of 
the  humerus. 

Ax  to  other  fornu  of  dis/oc((flon  at  the  elbow  it  may  be  noted  (1) 
that  both  bones  are  more  often  dislocated  together  than  separately  for 
the  radius  and  ulna  are  connected  by  powerful  ligaments,  the  radius 
and  humerus  are  not.  (2)  That  antero-posterior  displacements  are 
much  more  common  than  lateral  ones  on  account  of  the  lateral  width 
and  the  antero-posterior  narrowness  of  the  joint,  the  absence  of  lateral 
movement  and  the  presence  of  antero-posterior  movement,  the  feeble- 
ness of  the  antero-posterior  ligaments  and  muscular  support  and  the 
strength  of  the  lateral  ligaments  and  the  support  afforded  by  the 
lateral  muscles.  (3)  That  the  rarest  dislocation  of  both  bones  is  for- 
ward, for  it  is  resisted  by  the  large  strong  olecranon  process.  (4) 
That  if  but  one  bone  is  dislocated  it  is  most  often  the  radius,  for  it  is 
less  strongl}'  connected  with  the  humerus  and  more  exposed  to  indirect 
violence  through  the  hand. 

Dislocation  of  the  radius  alone  may  occur  in  the  forward,  backward 
or  outward  direction,  usually  forward.  In  luxation  of  the  radius  for- 
ward the  head  of  the  bone  arrests  flexion  of  the  elbow  at  or  near  90° 
by  im])act  upon  the  humerus.  It  may  be  due  to  direct  violence  from 
behind,  extreme  pronation  with  traction,  or  to  falls  upon  the  pronated 
or  supinated  hand  while  the  elbow  is  hyperextended.  The  elbow  is 
slightly  flexed,  almost  always  pronated  and  often  abducted.  Reduction 
may  usually  be  accomplished  by  traction  combined  with  supination, 
adduction  and  direct  pressure  upon  the  head  of  the  radius  but  it  is 
sometimes  resisted  or  recurrence  favored  by  the  interposition  of  a  por- 
tion of  the  capsule  or  the  torn  annular  ligament  between  the  head  of 
the  radius  and  the  humeral  condyle. 

Dislocation  of  the  radius  by  elongation  or  the  "  Suhluxatioji  of  the 
radius  of  young  eJiUdren"  is  an  injury  quite  common  between  the  ages 
of  one  and  three,  less  common  up  to  six,  and  is  due  to  forcible  traction 
on  the  extended  elbow,  possibly  combined  with  adduction  as  in  lifting 
a  child  or  holding  it  when  it  stumbles.  Symjitonis. — The  child  cries 
with  pain,  refuses  to  use  the  elbow,  which  is  slightly  flexed  ;  the  wrist 
is  pronated,  and  there  is  tenderness  over  the  head  of  the  radius. 
Passive  motion  is  free  except  for  supination.  The  injury  consists  in 
the  escape  of  the  anterior  portion  of  the  radial  head  below  the  orbic- 
ular ligament  and  is  readily  reduced  by  forcible  su]>ination  with  pres- 
sure backward  on  the  head  of  the  radius  followed  by  flexion  of  the 
elbow.     It  is  sometimes  spoken  of  as  sprain  of  the  elbow. 


FRACTURES  ABOUT  THE  ELBOW.  181 

Luxation  of  the  nlita  alone  is  usually  backward  but  may  rarely  be 
forward  or  inward.  Although  all  kinds  of  dislocations  of  the  elbow 
have  been  described  as  complete  or  incompldc  the  differences  are  often 
inconsiderable  and  unimportant.  Incomj)lete  forms  are  more  liable  to 
occur  in  the  lateral  tiian  in  the  antero-posterior  varieties. 

Fractures  of  the  /oicer  end  of  the  humerus  are  more  common  than 
those  of  the  upper  end  or  the  shaft  and  are  more  common  in  young  suh^ 
ject.s  than  in  adults.  Various  forms  occur,  rendering  a  differential 
diagnosis  necessary  and  often  difficult. 

A.  Supracondyloid  fractures  or  fractures  above  the  condyles  are 
due  to  cio/enee,  acting  as  a  rule  through  the  bones  of  the  forearm, y>/-ef.^- 
ing  the  lower  end  of  the  humerus  (1)  bachicard,  by  the  partly  flexed  fore- 
arm or  possibly  by  hyperextension  (''extension  fractures"),  (2)  for- 
ward from  beliind  (  "  flexion  fracture  "  )  or  (3)  inward  (  "  adduction 
fracture"),  (1)  is  oblique  from  behind  downward  and  forward  (the 
common  form  ;  (2)  is  oblique  in  the  opposite  direction  and  (o)  is  oblique 
from  above  and  externally  downward  and  inward.  Forms  (1)  and 
(2)  may  1)C  transverse  or  oblique  from  side  to  side.  The  character  and 
extent  of  the  di.^placcment  vary  with  the  direction  of  the  fracture. 

In  the  common  fomi  (1)  the  lower  fragment  with  the  bones  of  the 
forearm  is  displaced  backward  and  upward  by  the  original  violence 
aided  perhaps  by  the  triceps,  Ijiceps  and  brachialis  muscles.  Hence 
the  sharp  lower  end  of  the  upper  fragment  projects  forwards  and  the 
deformity  rcsendjlc.s  a  dislocation,  from  which  it  may  be  distinguii<hcd  by 
the  relative  position  of  the  two  condyles,  the  olecranon  and  the  radial 
head  (see  above,  p.  175)  and  by  the  fact  that  the  displacement  is 
readily  reduced  and  as  readily  recurs.  The  displacements  to  avoid  in 
the  treatment  are  overriding  and  a  lateral  angular  one  in  the  position 
of  adduction  {cuhitu.'^  rarus^,  due  to  the  support  of  the  elbow  by  the 
sling,  which  should  be  only  beneath  the  wrist,  and  perhaps  to  mus- 
cular action  or  a  primary  displacement  in  an  "  adduction  fracture " 
(form  (.3)). 

B.  A  T-shaped  or  intercondyloid  fracture  may  be  like  the  supra- 
condyloid form  with  the  addition  of  a  vertical  fracture  running  through 
the  thin  portion  of  the  bone  between  the  condyles  into  the  joint.  But 
as  they  are  commonly  due  to  great  violence  the  bone  is  often  much 
comminuted  and  the  fractures  run  in  various  directions,  the  essential 
fracturehelng  a  separation  of  both  condyles  from  each  other  and  from  the 
shaft.  On  theoretical  grounds  the  longitudinal  ridge  of  the  sigmoid 
cavity  has  been  thought  to  act  as  a  wedge  in  producing  the  vertical 
fracture  into  the  joint.  The  artery  or  nerves  about  the  joint  may  be 
torn  or  compressed  in  this  or  tiie  preceding  variety  but  less  frequently 
than  miglit  be  expected. 

For  surgical  purposes  the  terms  e]Mtrochlea  and  ej^icondyle  are 
applied  to  those  portions  of  the  internal  and  external  condyles  (respec- 
tively) which  are  outside  of  the  joint  capsule. 

C.  Fracture  of  the  epitrochlea  often  arcom panics  dislocation  of 
the  elbow,  wlieu  it   is  prol)ably  due  to  traction  of  the  forearm   flexor 


182  THE    UPPER  EXTREMITY. 

muscles,  or  it  may  be  due  to  direct  violence  from  behind.  The  r//,s- 
placement  may  be  downward  in  the  direction  of  the  muscles  attached 
to  it  but  the  dense  periosteo-aponeurotic  covering  and  the  attachment 
of  the  internal  lateral  ligament  prevent  much  displacement.  The 
epitrochlea  is  a  dij^tinct  epiphysis  which  joins  the  shaft  at  about  the  age 
of  eighteen,  and  before  this  age  may  be  separated  from  the  shaft  instead 
of  fractured. 

D.  Fracture  of  the  epicondyle  is  rare  if  it  ever  occurs,  and  many 
deny  the  possibility,  owing  to  its  small  size. 

E.  In  fracture  of  the  internal  condyle,  usually  due  to  a  fall  on 
the  flexed  elbow  or  to  forced  ad-  or  abduction  of  the  forearm,  the  line 
of  fracture  extends  from  the  inner  border  of  the  epitrochlea,  or  the 
ridge  above  it,  downward  and  outward  through  the  outer  part  of  the 
trochlea  or  even  beyond  it.  The  ulna  is  attached  to  the  fragment  and 
much  displacement  of  these  two  is  pjrevented  by  the  attachment  of  the 
former  to  the  radius,  unless  this  is  dislocated  as  occasionally  happens. 
A  late  lateral  displacement  in  the  adducted  position  (cubitus  varus)  may 
occur  in  this  as  in  supracondyloid  fractures,  from  the  same  cause  (see 
p.  181),  and  should  be  guarded  against.  The  relative  position  of  the 
epitrochlea  and  the  tip  of  tlie  olecranon  is  preserved  and  their  displace- 
ment with  reference  to  the  epicondyle  is  generally  too  slight  to  be 
recognized. 

F.  Fractures  of  the  external  condyle  are  more  common  than  those 
of  the  internal  condyle  and  are  esp<ci<dly  frequent  in  the  young.  They 
are  due  to  a  fall  on  the  hand  or  the  inner  and  back  part  of  the  flexed 
elbow  or  to  forcible  adduction  of  the  forearm.  The  line  of  fretcture 
runs  from  the  supracondylar  ridge  above  the  epicondyle  downward 
into  the  joint  usually  to  the  groove  of  the  trochlea,  coinciding  in  part 
with  the  epiphyseal  line.  In  children  it  is  likely  that  this  form  of 
fracture  often  consists  of  a  separation  of  the  capitellar  epiphysis, 
usually  combined  with  the  splitting  off  of  a  small  piece  from  the  outer 
side  of  the  diaphysis.  As  the  fragment  is  attached  by  ligaments  to 
both  the  radius  and  the  ulna,  the  displacement  is  usually  slir/ht,  but 
there  is  a  tendency  to  tilting  (flexion)  and  sometimes  to  a  rotation  of 
the  fragment.  As  in  fractures  of  the  internal  condyle  there  is  inde- 
pendent mobility  of  the  condyle,  usually  with  crepitus,  abnormal  lateral 
mobility  and  pain  on  transverse  pressure  and  at  the  point  where  the 
fracture  crosses  the  supracondylar  ridge.  In  both  forms,  even  witli 
satisfactory  reduction  of  the  displacement,  the  range  of  motion  may  be 
diminished  by  callus  obstructing  the  olecranon  or  coronoid  fossa,  etc. 

G.  Separation  of  the  lower  epiphysis  as  a  whole  is  rare  and  im- 
probal)le,  except  at  an  early  age,  on  account  of  its  irregular  outline. 
The  })ortion  comprising  the  united  epiphyses  of  the  radial  condyle, 
capitellum  and  trochlea  unite  with  the  shaft  in  the  seventeenth  year 
and  that  portion  including  the  capitellar  and  epicondylar  nodules  is 
not  infrequently  separated  in  the  elbow  injuries  of  children  (see  above). 
The  epitrochlea  unites  about  the  eighteenth  year.  A  prominent  feature 
of  several  of  the  reported  cases  has  been  a  backward  displacemod  of 


SURFACE  MARKINGS  AXD  LANDMARKS.  183 

the  forearm  (like  a  dislocation)  but  with  an  easy  restoration  to  place 
and  easv  recurrence  of  displace  nient. 

H.  Fracture  of  the  olecranon  is  commonly  due  to  (Ured  violence 
by  a  fall  upon  the  elbow  and  it  is  uncertain  what  action  if  any  the 
triceps  muscle  may  have  in  producing  or  assisting  in  the  production  of 
the  fracture.  The  /i))c  of  fracture  is  most  often  near  the  constriction 
at  the  middle  of  the  process  while  the  ejjiphy.si.s,  which  unites  with  the 
shaft  in  the  sixteenth  year,  comprises  only  the  summit  of  the  process. 

The  upper  fragment  is  seldom  much  separated  by  the  action  of  the 
triceps  as  it  is  held  to  the  hirer  fraf/ment  by  the  extension  of  the 
triceps  insertion,  the  internal  lateral  ligament  and  its  own  aponeurotic 
attachments,  which  are  usually  untorn.  In  fact  whatever  separation 
there  may  be  is  rather  due  to  the  descent  of  the  lower  fragment  in 
flexion  of  the  elbow.     The  repair  is  as  a  rule  by  fibrous  union. 

I.  Fracture  of  the  coronoid  process  is  very  rare  except  as  a  complica- 
tion of  backward  dislocation  of  the  ulna  or  of  both  bones  of  the  fore- 
arm. In  a  recent  case  of  this  kind,  owing  to  its  tilting  forward  and 
interfering  with  flexion  of  the  elbow  I  was  obliged  to  remove  it.  It 
cannot  be  caused  by  the  action  of  the  brachialis  as  the  latter  is  in- 
serted into  the  ulna  at  the  base  of  the  process  rather  than  into  the 
process  itself. 

J.  Fracture  of  the  head  or  neck  of  the  radius  is  rare.  Fracture  of  a 
part  of  the  head  is  sometimes  observed  in  dislocation  of  the  elbow.  I 
have  recently  observed  such  a  case  where  the  notch  could  be  felt  on 
rotation  of  the  radius  and  the  fragment  was  felt  in  close  proximity  but 
could  not  be  replaced,  and  was  removed. 

THE    FOREARM. 

This  region  extends  from  the  region  of  the  elbow  to  two  fingers' 
breadth  above  the  radial  and  ulnar  styloid  processes  (Joessel).  It  is 
coniccd  in  form,  pdtened  from  before  backward,  especially  in  muscular 
subjects,  more  rounded  in  women,  children  and  non-muscular  subjects 
on  account  of  the  accumulation  of  fat  in  front  and  behind  and  the 
slight  development  of  the  lateral  muscles.  On  account  of  its  conical 
form  circular  amputation  without  splitting  of  the  skin  flap  is  not 
appropriate  to  the  forearm. 

Surface  Markings  and  Landmarks. — The  xdna  can  be  felt,  along 
its  posterior  border,  the  entire  length  of  the  posterior  surface  of  the 
forearm.  In  muscular  subjects  its  position  is  marked  by  a  groove 
external  to  which  is  an  elevation,  extending  from  the  back  of  the 
external  condyle  down  the  middle  of  the  posterior  surface,  formed 
largely  by  the  extensor  communis.  Separated  from  this  by  a  groove 
is  another  prominence  on  the  outer  aspect  of  the  forearm,  formed  by 
the  braehioradialis  and  the  two  radial  extensors.  The  upper  fleshy  part 
of  these  muscles  covers  the  radius  so  that  its  upper  half  can  not  be  felt. 
But  in  the  lower  half  of  the  arm  its  lateral  surface  can  be  felt,  though 
less  plainly  than  the  ulna  for  it  is  covered  by  the  tendons  of  the  two 


184  THE    UPPER  EXTREMITY. 

radial  extensors  of  the  wrist  and,  about  two  inches  above  the  radial 
styloid  process,  it  is  crossed  by  the  extensors  of  the  thumb  which 
form  a  slight  ridge  directed  obliquely  downward,  outward  and  for- 
ward. On  the  anterior  surface  of  the  supinated  arm  in  thin  subjects 
two  slight  furrows  can  be  seen,  one  from  the  middle  of  the  bend  of 
the  elbow  to  a  point  just  internal  to  the  radial  styloid  process,  the 
other  from  the  internal  condyle  to  the  radial  side  of  the  pisiform  bone. 
These  two  furrows  represent  respectively  the  course  of  the  radial  and 
the  lower  two  thirds  of  the  ulnar  arteries,  along  which  one  incises  to  ligate 
them.  They  also  represent  the  anterior  borders  of  the  brachioradialis 
and  the  flexor  carpi  ulnaris  respectively.  The  course  of  the  upper 
third  of  the  idnar  artery  is  represented  by  a  line,  slightly  convex  in- 
ward, from  the  middle  of  the  bend  of  the  elbow  to  the  junction  of  the 
middle  and  u])per  thirds  of  the  line  indicating  the  course  of  the  rest  of 
the  ulnar  artery. 

The  skin  of  the  forearm  is  thin  and  movable  and  the  surface  veins 
show  through  it  unless  the  subcutaneous  fat  is  abundant.  It  is  to 
be  noted  that  over  the  middle  of  the  posterior  surface,  especially  in 
its  upper  part,  there  are  almost  no  veins  and  only  very  small  nerves, 
and  that  this  is  the  aspect  of  the  limb  most  exposed  to  injury.  The 
fascia,  which  in  the  upper  half  of  the  forearm  is  closely  attached  to  the 
muscles,  is  free  from  the  tendons  in  the  lower  half  and  attached  to  the 
posterior  borders  of  the  ulna  and  radius  so  as  to  incompletely  divide 
the  forearm  into  two  coinjjartinents  with  the  aid  of  the  interosseous 
membrane. 

Arteries. — The  free  anastomoses  between  the  radial  and  ulnar  arte- 
ries is  to  be  remembered  in  wounds  of  either  vessel.  ///  Ugating 
either  vessel  by  an  incision  along  the  lines  just  given  it  is  to  be 
noted  that  the  sheath  of  the  radial  is  connected  with  that  of  the  pro- 
nator radii  teres,  in  the  upper  half  of  the  forearm,  and  the  sheath  of 
the  ulnar  with  that  of  the  flexor  profundus,  upon  which  it  lies,  so  that 
to  freely  expose  these  arteries  the  sheaths  of  these  two  mnscles  must  be 
divided.  Also  in  Ugating  the  ulnar  artery  in  the  lower  two  third>^  of 
the  arm  the  idnar  nerve  is  almost  necessarily  cvposed  on  its  ulnar  side, 
while  in  ligating  the  radial  artery  the  radial  nerve  is  not  exposed  as  it 
lies  further  to  the  radial  side  and  is  connected  with  the  sheath  of  the 
brachioradialis.  Among  the  arterial  anomalies  of  practical  interest 
may  be  mentioned  :  (1)  the  perforation  of  the  deep  fascia  by  the  radial 
artery  in  the  middle  or  lower  third  of  the  forearm  and  its  subcutaneous 
course  around  to  the  back  of  the  first  interosseous  space.  It  can  be 
easily  injured  in  its  subcutaneous  }X)rtion  and  if  the  radial  pulse  is 
sought  in  its  usual  place  it  is  weak,  being  furnished  by  the  smaller 
superficialis  volse  branch.  (2)  In  case  of  a  high  origin  of  the  ulnar 
artery,  from  the  axillary  or  brachial,  it  usually  pierces  the  fascia  and 
becomes  superficial  a  little  above  the  elbow  and  thence,  passing  under 
or  sometimes  over  the  bicipital  fascia,  its  course  in  the  upper  third  of 
the  forearm  is  superficial,  covered  by  the  fascia  as  a  rule  but  some- 
times not. 


FRACTURES  OF  THE  RADIUS  AND    ULNA.  185 

Skeleton  of  the  Forearm. — Of  the  two  Ijones  the  ulna  is  tlie 
strongest  and  extends  furtliest  above,  the  radius  below,  and  the  two 
are  most  nearly  of  equal  strength  about  the  center  of  the  limb.  In  all 
parts  the  two  bones  are  iiefircr  the  posterior  than  the  anterior  aspect 
and  especially  so  in  the  upper  part.  They  are  nearest  the  center  of  a 
section  of  the  limb  in  the  lower  end  of  the  middle  third.  On  account 
of  the  posterior  position  of  the  bones,  especially  the  ulna,  they  are  best 
examined  or  reached  for  excision  on  this  aspect ;  also  fractures  are 
most  readily  compounded  posteriorly.  The  two  bones  approach  one 
another  above  and  below  and  arc  separated  in  the  middle,  the  separa- 
tion being  widest  a  little  below  the  middle  of  the  forearm.  In  supi- 
nation both  bones  are  parallel,  in  pronation  they  are  crossed.  The 
interosseous  space  is  narrowest  in  pronation,  widest  midway  between 
pronation  and  supination,  hence  the  latter  position  is  maintained  in 
most  fractures  of  the  forearm.  In  pronation  and  supination  the  ulna 
remains  stationary,  the  radius  revolving  around  it  describes  half  a  cone 
whose  apex  is  above  in  the  center  of  the  radial  head  and  the  base 
below.  Supination  is  the  stronejer  of  the  two  movements,  thus  in  using 
a  screw  driver,  gimlet,  or  cork  screw  the  main  force  is  applied 
during  supination.  In  ordinary  pronation  and  supination  there  is 
some  flexion  and  extension  of  the  elbow  and  rotation  of  the  shoulder 
in  addition  to  rotation  of  the  radius.  The  oblique  ligament  helps  to 
hold  the  radius  in  contact  with  the  humerus  through  the  medium  of 
the  ulna.  The  obliquity  of  the  fibers  of  the  interosseous  membrane 
(from  above  and  without  downward  and  inward)  makes  the  ulna  share 
with  the  radius  in  the  strain  of  the  latter  in  resting  on  or  pushing  with 
the  palm  and  communicates  to  the  radius  the  force  imparted  to  the 
ulna  in  a  blow  from  the  shoulder. 

Fractures  of  the  shafts  of  the  radius  and  ulna  may  be  due  to 
direct,  indirect  or  rarely  to  muscular  violence.  Fracture  of  the  ulna 
alone,  the  more  superficial  and  exposed  of  the  two  bones,  is  almost 
invariably  the  result  oi' direct  violence  such  as  a  blow  on  the  arm  raised 
to  protect  the  head,  for  in  this  position  the  ulna  becomes  uppermost. 
Fracture  of  the  radius  alone  is  also  generally  due  to  direct  violence  but 
is  more  often  the  result  of  indirect  violence  than  fracture  of  the  ulna, 
for  it  receives  all  shocks  transmitted  from  the  hand.  According  to 
Malgaigne  ^^green-stick  fracturci'^  are  more  common  in  the  forearm 
than  elsewhere. 

The  displacement  varies  greatly  with  the  direction  of  the  fracture 
and  the  fracturing  force  so  that  we  may  find  overriding,  lateral  or 
angular  displacement.  In  some  cases  it  is  afeeted  by  muscular  action. 
Thus  in  fracture  of  the  radius  alone  above  the  insertion  of  the  pronator 
teres  the  upper  fragment  may  be  fully  supinated  by  the  biceps  and 
supinator  (brevis)  while  the  lower  fragment  is  maintained  by  the 
splints  in  the  usual  position  midway  between  supination  and  pronation. 
If  union  occurs  with  the  fragments  in  these  relative  positions  the  power 
of  ."tupination  will  be  lost  as  the  supinators  can  act  no  further.  The 
same  result  may  follow  after  fractures  of  both  bones.     Another  im- 


186  THE   UPPER  EXTREMITY. 

portant  <Jl^pl<(cement  that  may  be  due  partly  or  entirely  to  muscular 
action  in  fracture  of  one  or  both  bones  between  the  two  pronators  is 
that  in  which  the  two  bones  approach  one  another.  The  upper  frag- 
ments of  both  bones,  or  of  the  radius  alone,  may  be  drawn  toward  the 
opposite  bone  by  the  pronator  teres  ;  and  the  louver  fragments  of  both 
or  either  bone  may  be  similarly  made  to  apjiroacli  the  opposite  bone  by 
the  pronator  quadratus  and  the  brachioradialis.  The  resulting  dimi- 
nution of  the  interosseous  space  or  the  actual  osseoii.^  union  between  the 
two  bones  interferes  with  or  entirely  prevents  rotation  of  the  radius, 
foi  the  performance  of  which  the  interosseous  space  is  essential.  Ex- 
cessive formation  of  callus  may  produce  a  similar  result.  Actual 
bony  union  of  the  two  bones  is  more  likely  to  occur  when  both  bones 
are  broken  at  the  same  level,  but  as  a  rule  the  radius  is  broken  nearer 
the  elbow  than  the  ulna. 

The  upper  fragment  of  the  radius  may  also  be  drawn  forward  by  the 
biceps  and  pronator  teres.  In  general  when  only  one  bone  is  broken 
the  other  acts  as  a  splint  to  prevent  marked  displacement,  except  the 
rotary  (supination)  displacement  of  the  radius  and  the  approach  of 
one  or  both  fragments  to  the  opposite  bone.  In  fracture  of  the  ulna 
alone  marked  displacement  of  its  fragments  may  occur  in  case  of  the 
not  infrequent  complication  of  dislocation  of  the  head  of  the  radius 
forward. 

In  treatment  the  following  points  should  be  observed  after  the  r//.s'- 
placeincnt  is  corrected  as  perfectly  as  possible.  If  there  is  any  tendency 
to  supincdion  of  the  upper  fragment  of  the  radius  the  forearm  should 
be  placed  in  the  supine  position  so  that  after  union  the  power  of  supi- 
nation may  be  preserved.  In  order  to  avoid  as  far  as  possible  the 
union  of  the  two  bone.s^  and  the  consequent  loss  of  rotation,  the  forearm 
should  be  placed  in  a  position  in  which  the  interosseous  interval  is 
widest,  i.  e.,  in  the  position  midway  between  pronation  and  supination. 
The  position  of  complete  supination  would  serve  equally  well  but  is 
more  irksome  to  the  patient.  With  the  object  of  preventing  union 
between  the  two  bones  the  use  of  graduated  pads  have  been  advised 
to  force  the  bones  apart  by  pressure.  But  this  pressure,  as  well  as 
any  undue  pressure  of  the  splints  and  bandages,  is  in  danger  of  pro- 
ducing gangrene  of  the  limb,  which  is  more  common  after  fracture  of 
the  forearm  than  after  fracture  elsewhere.  This  is  owing  to  the  fact 
that  most  of  the  venous  blood  is  returned  by  the  surface  veins  which, 
as  well  as  the  main  arteries,  are  readily  aifected  by  pressure. 

In  amputation  of  the  forearm,  the  jlap  method  is  best  suited  to 
the  upper  two  thirds,  the  circular  to  the  hnver  third.  In  the  latter  part 
the  soft  parts  are  mostly  skin  and  tendons  and  the  bones  come  closer 
to  the  sides  of  the  limb  so  that  the  flap  method  is  unsuitable.  As  the 
soft  ])arts  divided  are  mostly  tendons  they  are  more  easily  and  cleanly 
divided  from  within  outward  by  transfixion.  Arteries  and  nerves 
divided :  Fig.  46,  On  the  sides  of  the  anterior  or  flexor  aspect  of  the  cut 
surface  are  the  radial  and  ulnar  arteries,  the  former  no  longer  accom- 
panied by  its  nerve,  the  latter  with  the  ulnar  nerve  to  its  inner  side.     In 


PLATE    XIX 


MEDIAN    VEIN— s 


BRACH.-RAD 
MUSCLE 
RADIAL    ARTERY 

RADIAL    NERVE -j 

EXT.     CARP. ll_ 

RAD.     BREVIS   / 
MEDIAN    ARTERY     ' 

SUPINATOR 

ANTERIOR    I 
OSSEOUS   ARTERY 
EXT.    COM.    DIGIT 


FLEXOR 

CARPI     RAD. 
PRON  ATOR 


MEDIAN    NERVE 

\_FLEXOR    SUBL. 
\\  DIGIT, 

il. ULNAR    ARTERY 

ULNAR     NERVE 

j'  j/_FLEXOR    CARPI 
J  "   ;7  ULNARIS 


POSTERIOR     INTER 
OSSEOUS    NERVE 


FLEXOR    PROF. 
DIGIT. 


Cross  section  of   I'ight    forearni    at    lower  end   of    upper  third. 
Proximal  side  of  section,  from  below.     (Joessel.) 


FIO.   A7. 


BRACHIO 
RADIALIS 


FLEXOR 
LONGUS 
POLLICIS, 
RADIAL 


RADIAL 
NERVE 
EXT      OSSIS. 
METACARPI 
POLLICIS 


RADIAL    CARPAL 
EXTENSORS 


MEDIAN 
NERVE 

flexor! 

CARPI 


RADIALIS 


FLEXOR 
SUBLIMIS 
DEEP    LAYER 


R  A^D  1  'U  S 


EXT.     LONGUS 
POLLlCiS 


QUADRATUS 

ULNAR 

ARTERY 

ULNAR 

NERVE 


FLEXOR 
CARPI 
ULNARIS 


EXTENSOR    COM- 
MUNIS   DIG. 


ANT.     INTEROSS- 
EOUS   ARTERY 


EXT      CARPI 
ULNARIS 


Cross  section  of  right  wrist    1>^  cm.  above  articular  surface. 
Upper  segment   of  the  section.     (Tillaux.) 


THE  REGION  OF  THE    WRIST.  187 

front  of  the  interosseous  membrane  is  the  anteri(n'  interosseous  artery 
and,  with  the  median  nerve  in  the  posterior  layer  of  the  sheath  of  the 
flexor  sublimis,  is  the  median  artery,  sometimes  of  large  size.  Pos- 
teriorly between  the  deep  and  superficial  layers  of  muscles  is  the 
posterior  interosseous  nerve  and  artery. 

In  the  upper  two  thirds  of  the  arm,  where  the  muscular  masses  cover 
the  bones  at  the  sides  and  the  limb  is  more  flattened  and  conical,  ampu- 
tation bij  antcro-podcrior  fidps  is  more  suitable.  The  anterior  fiap  con- 
tains the  brachioradialis  and  the  flexor  muscles,  the  posterior  fnp  the 
extensor  muscles.  The  anterior  flap  is  more  sul)stantial,  as  the  bones 
He  nearer  the  posterior  surface.  The  radial  artery  with  the  radial 
nerve  run  the  whole  length  of  the  anterior  flap  and  are  cut  near  its 
outer  border,  internal  to  the  brachioradialis.  The  ufn((r  artery  is  cut 
at  a  higher  level,  in  front  of  the  ulna  and  between  the  superficial  and 
deep  flexors.  The  anterior  interosseous  artery  is  cut  short  just  in  front 
of  the  interosseous  membrane,  the  posterior  interosseous  is  cut  long 
between  the  superficial  and  deep  muscles.  The  principal  ney^es  are 
good  guides  to  the  corresponding  vessels. 

It  may  be  noticed  in  this  connection  that  the  ulnar  artery  gives  ofl^ 
the  interosseous  trunk  one  inch  below  the  bifurcation  of  the  brachial, 
which  occurs  opposite  the  upper  part  of  the  neck  of  the  radius.  As 
the  chief  pronators  are  the  pronators  teres  and  quadratus  and  the 
flexor  carpi  radialis  and  the  chief  supinators  are  the  biceps  and  supi- 
nator (brevis),  it  follows  that  in  amputation  above  the  insertion  of  the 
pronator  teres  (the  middle  of  the  arm)  the  radius  will  become  supi- 
uated  and  its  further  rotation  lost. 

THE  REGION  OF  THE  WRIST. 

This  region  may  be  artificially  limited,  according  to  Tillaux,  by 
planes  two  fingers'  breadth  above  and  below  the  radiocarpal  joint. 

Surface  Markings  and  Landmarks. — The  radial  and  ulnar  styloid 
■processes  can  always  be  made  out  and  are  the  most  important  lantl- 
marks  for  examination  of  or  operations  on  the  wrist.  The  radial  styloid 
process,  a  finger's  breadth  above  the  thenar  eminence,  is  more  anterior 
and  descends  one  half  inch  lower  than  that  of  the  ulna.  Partly  on 
account  of  this  fact  abduction  is  less  free  than  adduction  of  the  hand. 
The  radial  styloid  is  commonly  ca/T/'a/  upwai-d  i)i  Colles's  j'ractn re  so  as 
to  be  on  a  level  with  or  above  the  ulnar  styloid,  a  point  of  diagnostic 
importance.  Just  beneath  the  radial  and  ulnar  styloid  processes  one 
enters  the  radiocarpal  joints  the  line  of  irhieh  is  concave  inferiorly  and 
rises  1  cm.  above  that  connecting  the  styloid  processes.  In  pronation 
of  the  forearm  the  xhuir  styloid  jtrocc^s  is  less  distinct  and  the  bony 
prominence  at  the  back  of  the  ulnar  side  of  the  wrist  is  due  to  the 
head  of  the  ulnar.  The  ulnar  styloid  process  is  most  plainly  felt  in 
supination,  at  the  inner  and  posterior  aspect  of  the  wrist,  to  the  inner 
side  of  the  extensor  carpi  ulnaris  tendon. 

In  front  of  the  wrist  are  several  skin  creases  of  which  the  hueesf 
and  most  distinct  is  slightly  convex  downward   and  is  about  1   cm. 


188  THE   UPPER  EXTREMITY. 

below  the  radiocarpal  joint  (Tillaux).  If  the  line  of  this  crease  is 
continued  around  the  back  of  the  wrist  it  crosses  the  neck  of  the  os 
magnum  in  the  line  of  the  third  metacarpal  bone.  This  point  is  felt 
as  a  depression  in  extension  of  the  wrist,  but  is  replaced  by  a  promi- 
nence, the  head  of  the  os  magnum,  in  flexion  of  the  wrist.  This 
crease  also  indicates  fairly  well  the  upper  border  of  the  anterior  annular 
Uf/ament,  which  corresponds  to  the  lower  border  of  the  posterior  annu- 
lar ligament.  Above  the  thenar  and  hyjwthenar  eminences  is  a  slight 
depression  which  in  Colles's  fracture  forms  a  marked  angular  depres- 
sion and  serves  as  an  excellent  sign  of  this  injury,  according  to  Tillaux. 
About  and  below  the  point  where  the  flexor  carpi  radialis  tendon 
crosses  the  lower  skin  crease,  a  bony  rid(/e  can  be  felt,  formed  by  the 
tubercle  of  the  scaphoid  and  the  ridf/e  of  the  trapezium.  Correspond- 
ing to  this  level  at  the  base  of  the  hypothenar  eminence  the  pisiform 
can  be  still  more  readily  felt.  Below  the  head  of  the  ulna  at  the  back 
of  the  wrist  the  cuneiform  bone  may  be  felt  as  a  slight  prominence. 

Topography.  The  Front  of  the  Wrist. — On  the  radial  side  in 
the  (jroove  between  the  tendons  of  the  brachioradialis  and  flexor  carpi 
radialis,  which  is  most  marked  when  the  wrist  is  flexed,  can  be  felt  the 
radial  artery.  This  is  very  superficial,  lying  just  beneath  the  fascia 
and  hence  easily  exposed,  compressed  or  wounded.  It  is  here  that  the 
pulse  is  taken  and  arterial  sclerosis  looked  for.  To  the  ulnar  side  of 
the  flexor  radialis  tendon  is  the  most  prominent  tendon  of  this  region,  that 
of  the  pxdmaris  longus.  It  is  made  most  prominent  when  the  wrist  is 
partly  flexed,  the  thenar  and  hypothenar  eminences  adducted  and  the 
fingers  extended.  It  is  near  the  center  of  the  wrist.  In  the  groove 
between  the  two  last  named  tendons,  or  beneath  the  tendon  of  the 
palmaris  longus,  is  the  median  nerve  covered  by  the  deep  fascia.  As 
the  palmaris  longus  is  not  seldom  wanting  the/<:'.TOr  carpi  radifdis  tendon 
is  the  better  guide  to  the  nerve,  which  lies  between  it  and  the  flexor  sub- 
limis.  On  the  ulnar  side  the  flexor  carpi  ulnaris  can  be  felt  extending 
to  the  pisiform  bone.  It  is  made  most  prominent  by  slight  flexion  of 
the  wrist  and  adduction  of  the  little  finger.  In  the  groove  to  its  radial 
side,  between  it  and  the  more  deeply  placed  flexor  sublimis  tendons, 
lie  the  ulnar  artery  and  nerve,  the  latter  close  to  the  ulnar  side  of  the 
artery.  The  artery  and  nerve  are  covered  by  a  deep  and  a  superficial 
layer  of  the  deep  fascia  of  the  forearm  but  pierce  the  deep  layer,  which  is 
connected  with  the  sheath  of  the  flexor  sublimis,  just  above  the  anterior 
annular  ligament  in  order  to  pass  in  front  of  the  latter.  The  synovial 
sheath  for  the  superficial  flexors  and  that  for  the  long  flexor  of  the 
thumb  extend  up  the  wrist  above  the  annular  ligament  for  1^  to  IJ 
inches.  (Fig.  47.)  The  structures  above  named  at  the  front  of  the 
wrist  lie  upon  or  in  front  of  the  pronator  quadratus  muscle. 

At  the  outer  aspect  of  the  wrist  the  outer  surface  of  the  radius  is 
crossed  by  the  tendons  of  the  extensor  ossis  metacarpi  pollicis  and  ex- 
tensor brevis  pollicis.  These  tendons  are  made  very  prominent  by 
extension  and  abduction  of  the  thumb,  in  which  position  they  bound  ex- 
ternally a  depressed  triangular  space,  the  '^ snuff  box  space"  or  "  taba- 


PLATE    XX. 


FIG.  48. 


EXTENSOR    COMMU- 
NIS   DIGITORUM 
EXTENSOR     MINIMI 
DIGITI 
EXTENSOR    CARPI 
ULNARIS 


EXTENSOR    OSSIS 
METACARPI     POLLICIS 
EXTENSOR    BREVIS    POLLICIS 
EXTENSOR    LONGUS    POLLICIS 


EXTENSOR    CARPI 

RADIALIS    BREVIS 

EXTENSOR    CARPI 

3IALIS    LONGUS 


Synovial    membranes  of  tendons  on   the   dorsum  of  the   forearm 
and  hand,  artificially  distended.     (Gerrish,  after  Testut.) 


THE    WRIST  JOIST.  189 

tiere  anatomique"  of  French  writers,  whose  ulnar  boundary  is  formed 
by  tlie  extensor  longus  pollicis  tendon.  The  foor  of  the  .ijj«ice  is 
formed  by  the  scaphoid  and  trapezium  with  their  dorsal  ligaments  over 
which,  and  beneath  the  above  tendons,  runs  th^  rfidial  artery  in  its 
course  from  just  below  the  apex  of  the  styloid  process  to  the  back  of 
the  first  interosseous  space.  The  artery  is  here  covered  by  two  layers 
of  fascia  the  deeper  of  which  holds  it  close  to  the  carpal  bones.  Sub- 
cutaneously  the  radial  vein  and  branches  of  the  radial  nerve  cross  this 
space,  the  latter  vertically,  so  that  incisions  to  reach  the  artery  should 
be  iiKide  rrrficfd/y.  The  tendon-^  which  cross  the  outer  and  dorsal  sur- 
faces of  the  lower  end  of  the  radius  oceiipy  grooves  bounded  by  ridrjes 
of  which  that  on  the  radial  side  of  the  groove  for  the  extensor  longus 
pollicis  is  prominent  subcutaneously.  The  groove  for  this  tendon  in- 
dicates the  center  of  the  combined  dorsal  and  external  surfaces  of  the 
radius  and  corresponds  about  to  the  interval  between  the  scaphoid  and 
semilunar  bones.  Between  the  two  grooves  for  the  extensors  of  the 
thumb  is  one,  sometimes  divided  by  a  low  ridge,  for  the  short  and  long 
radial  extensors  of  the  wrist. 

On  the  dorsal  surfaca  of  the  wrist  on  the  ulnar  side  of  the  extensor 
longus  pollicis  is  a  shallow  groove  for  the  extensor  communis  and  ex- 
tensor indicis,  next  to  this  and  between  the  two  bones  a  groove  for  the 
extensor  minimi  digit!  and  between  the  head  and  styloid  process  of  the 
ulna  a  groove  for  the  extensor  carpi  radialis. 

The  order  and  relations  of  the  tendon.^  at  the  wrist  are  given  in 
detail  as  they  are  not  infrequently  severed  in  wounds  and  require  fen- 
don  .suture,  for  which  an  accurate  knowledge  of  their  position  and  rela- 
tions is  essential,  though  when  necessary  the  distal  part  of  a  tendon 
may  be  grafted  onto  another  muscle  with  good  results. 

The  .S-/.1-  grooves,  for  the  tendons  at  the  back  and  outer  side  of  the 
wrist,  are  converted  into  as  many  osseoaponeurotic  canals  by  the  poste- 
rior annular  ligament,  which  binds  down  the  tendons  and  prevents  their 
displacement  in  hyperextension  of  the  wrist.  This  ligament  is  con- 
tinuous with  and  a  thickening  of  the  fascia  of  the  dorsum  of  the  forearm 
and  hand.  In  these  six  canals  the  tendons  are  surrounded  by  .synovia/ 
sheaths.  (Fig.  48.)  The  sheaths  of  the  three  carpal  extensors  and  the 
extensor  ossis  metacarpi  pollicis  f.rtcnd  to  or  nearly  to  the  insertion  of 
their  tendons,  that  of  the  extensor  indicis  is  very  short,  the  sheaths  of  the 
other  tendons  extend  a  varying  distance  onto  the  dorsum  of  the  hand. 
All  the  sheaths  begin  above  near  the  upper  border  of  the  annular  liga- 
ment except  those  of  the  radial  extensors  which  commence  a  little 
lower  down.  The  sheath  of  the  extensor  ossis  metacarpi  and  extensor 
brevis  pollicis  is  the  one  most  often  inflamed  in  the  so-called  trno-syno- 
fitis  crepitans.  This  is  accompanied  by  swelling,  j)ain  and  crepitation 
on  motion  and  is  due  to  injury  or  unusual  use  of  those  muscles. 

The  Wrist  Joint. — The  .strength  of  tiie  radiocarpal,  or  wrist  joint, 
(hpcnd.s  Upon  the  number  of  .strong  (Igamrnts  and  tcndon-s  that  surround 
it,  the  absence  of  a  long  lever  on  its  distal  side  and  the  nearness  of  the 
numerous  small  bones  and  joints  of  the  hand  among  which  movements 


190  THE   UPPER  EXTREMITY. 

and  shocks  are  distributed.  Its  movements  are  largely  supplemented  by 
those  of  the  mediocarpal  joint.  In  the  wrist  joint  proper  extension  is 
most  free  and  its  strongest  ligament  is  the  anterior  which  limits  hyper- 
extension.  It  is  noteworthy  that  the  commonest  injury  is  from  forced 
extension,  for  in  falls  one  naturally  falls  upon  the  palm,  the  wrist 
being  extended,  rather  than  upon  the  dorsum,  the  wrist  being  flexed. 
The  dorsal  ligament  is  so  thin  and  superficial  that  swelling  is  first 
noticed  at  the  back  of  the  wu'ist  in  efi'usiou  into  the  joint.  In  disease 
of  the  joint  the  latter  is  held  midway  between  flexion  and  extension  as 
the  tendons  at  the  front  and  back  balance  one  another.  If  the  wrist 
joint  is  injected  one  notices,  especially  on  the  dorsum,  little  hernial  pro- 
trusions of  the  synovial  membrane  from  which  are  derived  most  of  the 
ganglia  which  are  so  common  in  this  situation.  At  first  these  com- 
municate with  the  joint,  but  as  a  rule  this  communication  becomes 
obliterated  as  the  pedicle  becomes  lengthened.  This  pedicle  may  often 
be  followed  by  dissection  as  a  fibrous  cord  connecting  the  ganglion 
with  the  surface  of  the  joint  capsule.  Similar  protrusions  are  to  be 
found  on  the  synovial  sheaths  of  the  tendons,  but  these  are  much  less 
often  the  starting  point  of  ganglia. 

Dislocations  of  the  wrist  are  rare,  for  in  the  common  form  of  vio- 
lence, due  to  a  fall  on  the  palm,  the  joint  is  protected  by  the  strong 
anterior  ligament  and  fracture  of  the  lower  end  of  the  radius  almost 
invariably  results.  The  dislocation  is  usually  forward,  less  often  back- 
ward, of  the  carpus  on  the  forearm.  It  is  usually  due  to  great  violence 
and  hence  is  often  compound  and  sometimes  complicated  by  rupture  of 
tendons  or  fracture  of  adjacent  bones.  I  hav' e  recently  seen  a  compound 
backward  dislocation  in  which  the  semilunar  bone  projected  forward 
through  the  anterior  wound,  and  was  almost  entirely  detached.  Both 
forms  may  be  due  to  violence  applied  to  the  flexed  or  extended  wrist. 
The  deformiti/  of  backicard  dislocation  closely  rexendiles  that  of  Collet's 
fracture  but  in  the  former  the  swelling  in  front  of  the  wrist  extends 
further  down  and  ends  more  abruptly,  that  at  the  back  of  the  wrist  is 
more  sharply  outlined  at  its  upper  border.  In  addition  the  hand  is 
usually  more  flexed  and  less  movable  in  dislocation. 

In  tiie  inferior  radioulnar  joint  the  triatigular  fibrocartilage  is  the 
principal  ligament  and  the  strongest  ligamentous  connection  between 
the  two  bones.  The  synovial  cavity  of  this  joint  is  usually  separate 
from  that  of  the  radiocarpal  joint.  Dislocation  of  this  joint,  apart  from 
that  sometimes  observed  in  connection  with  Colles's  fracture,  is  very 
rare.  It  is  usually  forward  or  backward  of  the  ulna.  In  the  latter 
form  it  is  usually  due  to  exaggerated  pronation,  so  that  the  hand  is 
pronated  and  supination  is  interfered  with.  The  forward  form  has 
been  due  to  direct  violence  and  the  wrist  may  be  pronated  or  supinated 
and  rotation  is  difficult.  The  ulna  is  prominent  at  the  front  or  back 
of  the  wrist  according  to  the  form  of  dislocation.  Some  surgeons  have 
thought  that  tlie  injury  described  above  (p.  180)  as  subluxation  of  the 
head  of  the  radius  in  young  children  is  a  dislocation  of  the  lower  end 
of  the  ulna. 


COLLES'S  FRACTURE.  191 

CoUes's  fracture  is  one  through  the  lower  end  of  the  radius  from 
I  to  1  inch  above  its  articular  surface,  at  or  near  the  point  where  the 
compact  tissue  of  the  shaft  joins  the  cancellous  tissue  of  the  lower 
extremity,  which  appears  to  be  a  weak  spot.  It  is  one  of  the  com- 
iiioned  Jracturcii  and  is  most  frequent  in  the  elderly.  The  direction 
is  transverse,  usually  with  a  slight  obliquity  upward  and  backward 
and  sometimes  with  a  moderate  slant  upward  and  outward.  The 
lower  fragment  usually  shows  a  moderate  backward  (tiKplacement  with 
considerable  backward  and  often  some  outward  rotation.  Thus  the 
articular  surface  looks  downward  and  backward  instead  of  downward 
and  forward  as  normally.  Iinpudion  of  the  upper  fragment  into  the 
cancellous  tissue  of  the  dorsal  and  lateral  part  of  the  lower  is  the  rule, 
and  coinininidion  of  the  lower  fragment  is  frequent.  In  addition  the 
ulnar  styloid  process  may  be  fractured  by  avulsion  by  means  of  the 
internal  lateral  ligament  rather  than  by  the  fibrocartilage. 

The  deformity  in  typical  cases  is  characteristic.  The  prominence  on 
the  dorsum  over  the  lower  fragment,  due  to  its  backward  displace- 
ment and  rotation  and  to  swelling,  gave  origin  to  the  name,  given  by 
Velpeau,  "  silver  fork  fracture,"  on  account  of  the  resemblance  of  its 
outline  as  seen  from  the  radial  side.  The  end  of  the  idna  is  veri/ 
proniuient  in  front  on  account  of  the  displacement  upward,  backward 
and  somewhat  outward  of  the  lower  fragment  of  the  radius  and  of  the 
carpus  which  preserves  its  relations  with  it.  The  prominence  in  front 
over  the  lower  end  of  the  upper  fragment  is  mostly  due  to  swelling  of 
the  soft  parts.  The  radial  styloid  is  displaced  up  to  or  above  the  level 
of  the  ulnar  styloid  and  the  transverse  creases  in  front  of  the  wrist  are 
deepened.  Crepitus  and  abnormal  mobility  are  not  present  in  cases 
with  marked  impaction  and  may  not  be  easily  recognizable  in  other  cases. 

The  cause  of  Colles's  fracture  is  almost  always  a  fall  upon  the  palm 
of  the  hand.  The  mechanism  is  neither  simple  nor  constant  and  has 
been  and  is  still  much  disputed.  (1)  The  fracture  is  due  to  a  crush- 
ing of  the  cancellous  tissue  between  the  carpus  and  the  shaft,  the 
weight  of  the  body  being  received  in  the  long  axis  of  the  radius  while 
it  is  within  30°  of  the  vertical.  (2)  The  axis  of  the  radius  being 
more  oblique  and  not  in  line  with  the  fall  the  force  is  dcconijiosed, 
part  of  it  passing  up  the  shaft  in  the  long  axis  of  the  radius  and  part 
acting  transversely  to  break  the  bone  at  its  weakest  point.  The  back- 
ward rotation  and  displacement  of  the  lower  fragment  indicates  the 
direction  of  this  latter  part  of  the  force,  (o)  The  fracture  is  due  to  a 
cross-strain  exerted  on  the  lower  end  of  the  radius  through  the  strong 
anterior  ligament,  made  tense  by  hyperextension  of  the  hand.  The 
bone  is  broken  by  avulsion  on  the  princi])le  that  a  stout  ligament  is 
stronger  than  cancellous  bone,  so  that  the  latter  gives  way  first.  Most 
fractures  are  j)rol)ably  produced  in  one  or  the  other  of  the  first  two 
ways.  There  is  no  doubt  that  it  can  be  and  sometimes  is  produced  by 
avulsion.  This  theory  rests  upon  experiments  on  the  cadaver  and  is 
supported  by  many  French  and  German  writers  on  surgical  anatomy 
(Tillaux,  Joessel,  etc.). 


192  THE   UPPER  EXTREMITY. 

Epiphyseal  separation  is  probably  more  often  due  to  this  mechan- 
ism. The  cpipki/siK  joins  the  shaft  in  the  twentieth  year  ;  it  includes 
the  insertion  of  the  brachioradialis  and  the  facet  for  the  ulna.  The 
line  of  the  epiphyseal  cartilage  is  nearli/  horizontal  and  may  be  intra- 
syuovial  internally.  Arrest  of  growth  of  the  radius  has  followed 
epiphyseal  separation  in  young  subjects. 

Complete  reduction  of  the  displacement  in  Colles's  fracture  is  often 
difficult  but  is  essential  to  prevent  permanent  deformity  and  to  insure 
perfect  function.  It  is  noteworthy  that  the  X-ray  shows  a  decidedly 
lower  position  of  the  articular  surface  of  the  radius  as  compared  with 
that  of  the  ulna  in  the  female  than  in  the  male. 

Amputation  at  the  wrist  joint  is  rareli/  performed.  Its  principal 
object  is  to  save  the  movements  of  pronation  and  supination.  In  most 
cases  of  injury  it  will  either  be  necessary  to  amputate  higher  or  it  will 
be  possible  to  save  more,  even  a  finger,  which  is  most  desirable.  In 
cases  of  disease  the  necessary  skin  covering  is  involved  and  the  move- 
ments of  rotation  are  often  lost  from  the  disease.  In  general,  ampu- 
tations in  which  the  bones  are  left  covered  with  cartilage  are  objection- 
able, as  the  latter  has  almost  no  reparative  action.  The  elliptical 
method,  resembling  that  by  long  palmar  flap,  is  the  best.  In  it  the 
cicatrix  is  dorsal,  the  stump  is  covered  by  the  tough  and  well-nourished 
tissues  of  the  palm  and  the  styloid  processes  are  well  covered.  The 
great  retract ibil it y  of  tJie  ski)i  on  the  dorsum,  due  to  the  looseness  of 
the  subcutaneous  tissues,  should  be  remembered.  Disarticulation  is 
easier  from  the  dorsum.  The  radied  artery  is  cut  at  the  outer  end  of 
the  dorsal  wound,  the  ulnar  at  the  inner  end  and  the  superjicialis  voice 
at  the  outer  portion  of  the  palmar  flap. 

Excision  of  the  wrist  includes  the  removal  of  the  carpal  bones 
and  usually  the  articular  ends  of  the  bones  of  the  forearm  and  meta- 
carpus. As  the  joints  are  covered  and  protected  by  strong  tendons 
which  move  the  wrist  and  fingers  and  which  (save  those  of  the  pal- 
maris  longus  and  flexor  carpi  ulnaris)  are  surrounded  by  synovial 
sheaths,  the  incisions  are  planned  so  as  to  spare  these  tendons  and  their 
sheaths  as  far  as  possible.  Including  that  of  the  pisiform  there  are 
seven  separate  synovi(d  sacs  in  the  joints  of  the  wrist  and  carpus.  It  is 
important  to  spare  the  radial  artery  which  is  close  to  the  first  carpometa- 
carpal joint  (dorsally)  the  deep  palmar  arch  (see  p.  197)  and  if  possi- 
ble the  annular  ligaments.  In  Ollier''s  method  the  dorsoradial  incision 
is  along  the  radial  border  of  the  extensor  indicis  tendon,  between  it 
and  that  of  the  extensor  longus  pollicis,  the  ulnar  incision  is  along  the 
inner  side  of  the  extensor  carpi  ulnaris.  The  pisiform  bone  may 
usually  be  left  and  the  trapezium  should  be  when  possible.  Unless 
the  subperiosteal  method  is  employed,  and  this  is  often  difficult,  the 
tendons  of  the  extensors  and  flexors  of  the  carpus  are  severed  or 
detached.  Another  simple  and  satisfactory  method  is  to  split  the  hand 
between  the  second  and  third  metacarpal  bones,  between  the  trapezius 
and  OS  magnum  and  between  the  scaphoid  and  semilunar  by  an  incision 
between  the  extensor  indicis  and  the  extensor  communis  tendons. 


THE  HAXD  AM)  FINGERS. 


V33 


THE  HAND  AND  FINGERS. 

Surface  Markings  and  Landmarks.  Palmar  Surface. — Between 
the  thenar  eminence  on  tlie  radial  side  and  the  hypothenar  eminence  on 
the  ulnar  side  is  the  "  ho//o>r  of  the  lianci/'  a  concavity  of  a  somewhat 
triangular  outline.  Its  apex  is  above  and  it  is  limited  below  by  tliree 
little  elevations  opposite  the  clefts  between  the  fingers.  These  eleva- 
tions are  due  to  the  projection  of  the  fatty  tissue  between  the  flexor 
tendons  and  the  digital  slips  of  the  palmar  fascia,  which  form  the 
grooves  between  these  elevations.  The  hollow  of  the  hand  is  more 
marked  in  the  position  of  flexion  and  in  muscular  subjects.  The  bony 
prominences  at  the  proximal  ends  of  the  thenar  and  hypothenar  emi- 
nences have  already  been  referred  to. 

Fig.  49. 


SUPERFICIAL^-! 
PALMAR  ARCH 


DEEP 

PALMAR  ARCH 


ULNAR 
ARTERY 


RADIAL  ARTERY 


Position  of  the  principal  creases  of  the  palmar  surface  and  of  the  jmlmar  arches. 


Three  of  the  many  creases  in  the  skin   of  the  jxi/m  deserve  notice. 

The  first  murks  off  the  thenar  eniinonce  from  the  hollow  of  the  ])alm. 

It  starts  at  the  wrist  and  ends  at  the  radial   border  of  the  palm  at  the 

base  of  the  index  finger.     The  second  starts  on  the  radial  border,  at 

13 


194  THE   UPPER  EXTREMITY. 

or  just  below  the  last,  and  crosses  the  palm  obliquely  inward  and  up- 
ward to  the  hypothenar  eminence.  The  third  and  lowest  starts  from 
the  elevation  opposite  the  cleft  between  the  first  and  second  fingers  and 
runs  obliquely  to  the  ulnar  border.  The  first  is  due  to  the  opposition 
of  the  thumb,  the  second  to  the  flexion  at  the  metacarpo-phalangeal  joint  of 
the  index  and  middle  fingers,  the  third  to  the  similar  flexion  of  the  inner 
three  fingers.  Topographically  the  second  fo/d,  where  it  crosses  the  third 
metacarpal  bone,  is  just  below  the  lowest  point  of  the  superficial  pal- 
mar arch,  and  the  third  fold  crosses  the  necks  of  the  metacarpal  bones, 
roughly  indicates  the  upper  limit  of  the  synovial  sheaths  of  the  mid- 
dle and  ring  fingers,  and  lies  a  little  above  the  division  of  the  palmar 
fascia  into  its  digital  slips.  The  metacarpophalangecd  joints  lie  about 
midway  between  this  fold  and  the  webs  of  the  fingers. 

The  uppermost  of  the  folds  across  the  front  of  the  fingers  separate  them 
from  the  palm,  and  are  on  a  line  with  the  webs  of  the  fingers  and 
12—15  mm.  below  the  metacarpophalangeal  joints.  The  upper  of 
the  middle  series  of  folds  are  opposite  the  first  iuterphalangeal  joints 
and  the  lowest  set  of  folds  are  2^  mm.  above  the  second  iuter- 
phalangeal joints.  On  the  thumb  the  two  creases  correspond  to  the  two 
joints,  the  upjier  crease  crossing  the  joint  obliquely. 

Dorsal  Surface. — The  proximal  ends  of  the  first  and  fifth  meta- 
carpal bones  are  prominent  and  can  be  readily  felt.  A  line  slightly 
concave  downward,  joining  the  upper  ends  of  these  and  1  cm.  below 
the  lowest  skin  crease  in  front  of  the  wrist,  indicates  the  line  of  the 
carpometacurpcd  joints.  When  the  fingers  are  flexed,  the  prominence.^ 
of  the  liiuckles  are  formed  by  the  proximal  bone  of 
Fig.  50.  g^ch  joint  (Fig.  50),  so  that  the  joint  line  lies  be- 

low the  prominences  by  one  twelfth  inch  in  the 
distal,  one  sixth  inch  in  the  middle  and  one  third 
inch  in  the  proximal  joints.  The  first  dorsal  inter- 
osseous muscle  forms  a  prominence  between  the  first 
and  second  metacarpal  bones,  when  the  thumb  is 
adducted. 

The  skin  of  the  palm  and  of  the  palmar  surface 

Outline  to  show  the  i*  ii         j?  •     j/  •   7  i     i  1        -ii         i.    1      • 

relation  of  the  bent  ot  the  Hugers  IS  thick  and  dcusc  and  without  hairs 
iines.'''^\h°e*''shadrd  o^'  sebaccous  glands.  Beneath  the  epidermis,  which 
epiphyses'^^'^^*^"*  ^^^  '^^  particularly  thick,  small  subepidermal  abscesses  often 
develop.  The  .s7:/**  of  the  dorsum  of  the  hand  is  much 
thinner  and  down  to  the  second  or  third  phalanges  is  supplied  with  nu- 
merous hairs  and  sebaceous  follicles  and  hence  is  liable  to  furuncles  and 
other  lesions  associated  with  these  .structures.  The  shin  of  tlie  pcdm  is 
more  abundantly  supplied  with  sireat  glands  than  any  other  part  of  the 
body,  four  times  more  so,  according  to  Sappey.  Hence  the  profuse  per- 
spiration that  may  occur  here,  as  is  well  known.  The  Pacinian  bodies 
and  tactile  corpuscles  in  connection  with  the  free  cutaneous  nerve  sup- 
ply are  more  numerous  on  the  palmar  aspect  than  elsewhere  in  the 
body.  The  palmar  aspect  of  the  third  phalanx,  especially  that  of  the 
index  finger,  is  most  sensitive  and,  with  the  exception  of  the  tip  of  the 


THE  PALMAR   FASCIA.  195 

tongue,  possesses  more  acute  tactile  sensibility  than  any  other  part. 
The  dorsum  of  the  hand,  on  the  contrary,  is  but  little  sensitive  to  tactile 
sensation.  The  area  around  the  upper  end  of  the  nail  is  liable  to 
superficial  subepidermal  abscesses  ("run  around"  paronijcliid)  which 
develop  quickly. 

The  subcutaneous  tissue  on  the  palmar  aspect  intimately  connects 
the  overlying  skin  with  the  underlying  fascia  in  the  palm,  and  with 
the  tendon  sheaths  in  the  fingers.  Hence  subcutaneous  inflammatory 
or  bloody  extravasations  and  oedema  are  practically  impossible  here, 
while  on  the  dorsum,  where  the  subcutaneous  tissue  is  lax  and  abundant, 
swelling  and  oedema  may  be  very  marked.  For  the  same  reason 
wounds  do  not  gape  on  the  palmar  surface  but  gape  widely  on  the 
dorsum.  The  denseness  of  the  skin  and  underlying  parts  on  the  palm 
renders  inflammation  very  painful  on  account  of  the  tension  caused  by 
the  inflammatory  products,  while  on  the  dorsum  the  reverse  is  the 
case.  Another  particular  in  Avhich  the  coverings  of  the  palm  rescndjle 
the  scalp  is  in  the  arrangement  of  the  subcutaneous  fat,  the  lobules  of 
which  are  contained  in  small  fibrous  compartments  of  the  subcutaneous 
tissue.  This  arrangement  of  the  skin  and  underlying  tissues  of  the 
palm  adapts  it  to  resist  the  eflfects  of  pressure  and  friction.  Thus  the 
ulnar  border  of  the  palm  is  much  used  in  resting  on  the  hand  and  in 
hammering  movements,  and  it  is  noteworthy  that  the  soft  parts  here 
are  singularly  free  from  large  nerves.  The  palmar  aspect  is  singu- 
larly//re //-oy/j  large  surface  veins,  which  are  abundantly  found  on  the 
dorsum  of  the  hand.  The  lymph  vessels,  on  the  contrary,  are  more 
numerous  on  the  palmar  surface  of  the  hand  and  fingers. 

The  palmar  fascia,  in  its  central  portion  beneath  the  hollow  of  the 
palm,  is  very  dense  and  thick  and  is  triangular  in  form.  Its  uprpjer  end 
is  connected  with  the  lower  border  of  the  annular  ligament  and  of  the 

CI 

palmaris  longus,  of  which  it  is  the  degenerated  distal  end.  Its  lower 
end  or  haxc  splits  into  four  slips  which  join  the  fibrous  tendon  sheaths 
of  the  fingers  and  send  fibers  to  the  skin,  and  deep  transverse  ligaments. 
The  digital  vessels  and  nerves  and  the  lumbricales  emerge  in  the  inter- 
val between  these  slips.  The  denseness  of  the  fascia  well  protects  the 
soft  parts  beneath. 

Dupuytren's  contracture  is  a  peculiar  contraction  of  the  palmar 
fascia  and  its  slips,  especially  those  going  to  the  ring  and  little  Jingcrs. 
It  occurs  especially  in  men  after  middle  life  and  may  be  associated 
with  traumatism.  It  gradually  flexes  the  first  and  then  the  second 
phalanges  onto  the  palm.  The  tendons  are  not  involved  but  between 
them  and  the  thickened  projecting  cord-like  slips  of  fascia,  which  are 
connected  witli  and  wrinkle  the  skin,  is  a  layer  of  fatty  connective 
tissue. 

Laterally  the  palmar  fascia  is  continued  as  a  thinner  layer  over  tiie 
thenar  and  hypothenar  eminences.  A  fibrous  membrane  connects  the 
deep  surface  of  the  palmar  fascia,  on  each  side  of  the  central  por- 
tion, with  the  interosseous  fascia  covering  the  palmar  interossei.  In 
this  way  two  latcnd  (thenar  and  hypothenar)  and  a  central  compart- 


196  THE   UPPER  EXTREMITY. 

ment  are  formed.  Suppuration  commencing  in  any  of  these  spaces 
may  be  limited  to  that  space  for  a  time  but  the  membranous  septa  are 
thin  and  may  soon  yield.  The  central  compariment  i.s  coufinuous  above, 
beneath  the  annular  ligament  and  along  the  flexor  tendons,  with  the 
wrist  and  forearm.  It  is  continuouft  below  irith  the  sheaths  of  the 
flexor  tendons  and  the  three  intervals  between  the  digital  slips  of  the 
fascia  which  correspond  to  the  webs  between  the  fingers.  Hence  pus  in 
the  central  compartment  of  the  palm  makes  its  way  up  into  the  forearm 
or  down  along  or  between  the  fingers.  The  resistance  offered  by  the 
palmar  fascia  is  so  firm  that  rather  than  perforate  it  pus  makes 
its  way  through  the  interosseous  spaces  to  the  dorsum,  though  this 
course  is  resisted  by  a  layer  of  fascia  covering  the  deep  palmar  arch 
and  the  interossei  muscles.  This  fascia  joins  the  membranes  separating 
the  central  compartment  of  the  palm  from  the  thenar  and  hypothenar 
compartments  in  front  of  the  third  and  fourth  metacarpal  bones  re- 
spectively. 

Practically  abscesses  of  the  palm  may  be  divided  into  those  in  front 
of  and  those  behind  the  palmar  fascia.  Abscesses  in  front  of  the  fascia, 
whether  subepithelial  or  subcutaneous,  are  small,  confined  to  the 
palm  and  very  painful,  but  the  pain  is  limited  to  the  palm.  Sub- 
fascial abscess  may  spread  to  the  fingers,  wrist  and  forearm  or  to  the 
dorsum,  which  is  usually  much  swollen.  The  pain  is  intense  and  is 
felt  along  the  course  of  the  nerves.  In  openiiu/  abscesses  of  the  palm 
and  in  all  operations  on  the  palm  the  incision  should  be  vertical,  parallel 
with  the  tendons  and  digital  nerves  and  above  or  below  the  superficial 
palmar  arch  (see  p.  197).  If  an  incision  is  required  in  the  wrist  it 
should  be  vertical  and  to  the  ulnar  side  of  the  palraaris  longus  tendon, 
where  it  will  avoid  the  uhiar  and  radial  arteries  and  the  median  nerve. 

The  fibrous  sheaths  of  the  flexor  tendons  extend  from  the  metacarpo- 
])halangeal  joints  to  the  upper  ends  of  the  last  phalanx  at  the  insertion 
of  the  profundus  tendons.  Tliere  being  no  intervening  fascia  here,  the 
skin  and  subcutaneous  tissues  are  connected  with  these  sheaths  in  tlie 
same  intimate  way  as  with  the  fascia  in  the  palm.  The  sheaths  arch 
across  the  front  of  the  phalanges  between  their  lateral  margins  and 
thus  form  semicylindrical  canals  which  lodge  the  synovial  sheaths. 
The  fibrous  sheaths  are  dense  and  rigid  so  as  to  remain  open  when 
cut,  so  that  in  amputation  of  the  fingers  an  open  channel  leading  up  to 
the  palm  is  left  for  the  spread  of  infection.  Opposite  the  joints  of  the 
fingers  the  sheaths  are  thin  and  lax,  leaving  spaces  between  their 
obliquely  decussating  fibers  through  which  the  synovial  lining  may 
])rotrude  and  suppuration  may  find  its  way  into  the  interior  of  the 
sheath. 

Two  synovial  tendon  sheaths  are  found  in  the  palm,  the  outer  for 
the  flexor  longus  jjollicis,  the  inner  for  the  superficial  and  deep  flexors 
of  the  fingers.  These  extend  up  beneath  the  annuhir  ligament,  where 
tliey  are  constricted,  and  for  about  1}  inches  above  it  into  the  wrist. 
Inferiorly  the  outer  one  extends  to  the  insertion  of  the  flexor  longus 
pollicis,  the  inner  one  to  the  insertion  of  the  flexor  profundus  of  the 


PLATE    XXI 


FIG.  51. 


,        MEDIAN     NERVE 
\     SHEATH    OF    FLEXOR 
CARPI     RADIALIS 


ULNAR    NERVE 


PALMAR    SHEATH    OF 
FLEXOR    TENDONS 
OF    FINGERS 


TENDON    OF    FLEX.     \    j    / jl 


SUBL.     DIGIT 


TENDON    OF    FLEX. 


Tendon  sheaths  and  muscles  of  the  pah"nar  surface 
of  the  left  hand.     (Joessel.) 


THE  PALMAR   ARCHES.  197 

little  finger  and  to  about  the  middle  of  the  metacarpal  bone  for  the 
otiier  three  fingers,  but  further  down  on  the  tendons  of  the  ring  finger 
than  on  those  of  the  other  two.  On  the  ring,  middle  and  index 
fingers  the  dif/ifa/  si/novial  slicatJis  commence  opposite  the  heads  of  the 
metacarpal  bones  and  extend  to  the  insertion  of  the  profundus  tendons, 
being  contained  within  the  fibrous  sheath.  (Fig.  51.)  They  are  thus 
separated  by  one  fourth  to  one  half  inch  from  the  main  palmar  syno- 
vial sheath  of  the  flexor  tendons.  Hence  operations  on  and  inflamma- 
tion of  the  thumb  and  little  finger  are  more  serious  than  of  the  oth«r 
fingers,  for  inflammation  in  the  former  may  more  readily  spread  to  the 
synovial  sac  of  the  palm,  causing  a  swelling  here,  which  is  constricted 
beneath  the  annular  ligament  and  is  expanded  again  in  front  of  the 
wrist.  This  is  seen,  not  infrequently,  in  case  of  felon  of  these  two 
fingers.  As  the  two  sheaths  may  communicate  normally  or  patholog- 
ically inflammation  may  spread  from  the  thumb  to  the  little  finger  or 
vice  versa,  giving  rise  to  a  horseshoe-shaped  swelling.  The  two  pal- 
mar sacs  may  be  the  seat  of  cysts  which  show  the  characteristic  form  of 
the  sacs.  In  case  of  tubercular  inflammation  here  and  in  the  sheaths 
of  the  extensor  tendons  at  the  back  of  the  wrist  the  sheaths  are  filled 
with  fibrinous  masses  known  as  rice  bodies. 

The  superficial  palmar  arch  (Fig.  49)  lies  beneath  the  palmar  fas- 
cia and  suj)erficial  to  the  flexor  tendons.  Its  course  is  represented  by 
a  line,  slightly  convex  downward,  commencing  at  the  radial  side  of  the 
pisiform  bone  and  crossing  the  palm  in  line  with  the  palmar  aspect  of 
the  thumb,  when  abducted  at  rigiit  angles  with  the  index  finger.  This 
line  should  be  (a-oided  if  possible  ///  incisions  in  the  palm.  The  deep 
arch  (Fig.  49)  lies  about  one  half  inch  nearer  the  wrist,  in  front  of  the 
bases  of  the  metacarpal  bones,  and  beneath  the  deep  or  interosseous 
fascia.  It  is  nearer  the  dorsal  than  the  palmar  surface  and  is  more 
liable  to  injury  from  the  former  aspect.  The  bifurcation  of  the  digital 
arteries  occurs  about  one  half  inch  above  the  webs  of  the  fingers. 

The  blood  suppli/  of  the  fingers  is  very  abundant,  the  pulp  of  the 
fingers  being  one  of  the  most  vascular  parts  of  the  body.  It  is  owing 
to  this  fact  that  in  so  many  cases  the  tip  of  the  finger,  accidentally  cut 
off,  has  grown  on  again  when  reapplied  at  once. 

Wounds  of  the  palmar  arches  and  their  branches  are  serious  on 
account  of  the  dijficidty  of  cliwking  tike  Iwuiorrhage.  This  is  due  to  the 
danger  of  damaging  important  structures  of  the  palm  and  to  the  free 
anastomosis,  whereby  ligature  of  either  the  radial  or  ulnar  or  both  does 
not  control  the  bleeding,  for  the  arches  anastomose  with  each  other 
and  with  the  carpal  arches,  which  communicate  with  the  two  inter- 
osseous vessels  above.  Hence  the  two  ends  of  the  divided  artery 
should  be  secured  if  possible  but,  if  the  wound  is  deep  or  narrow, 
pressure  may  often  arrest  the  bleeding.  The  possibility  that  pressure 
may  cause  gangrene,  owing  to  the  rigidity  of  the  parts,  should  be 
borne  in  mind. 

Beneath  the  superficial  arch  and  superficial  to  the  flexor  tendons  is 
the  median  nerve  in  the  groove  between  the  long  flexor  of  the  thumb 


198  THE   UPPER  EXTREMITY. 

and  the  flexors  of  the  fingers.  The  nerve  supply  of  the  hand  and  fingers 
is  of  interest  and  practical  importance. 

Cutaneous  Nerve  Supply  (Figs.  52  and  53).  Palmar  Surface. — The 
palm  is  supplied  by  the  median  and  ulnar  nerves  M'hich  anastomose 
with  one  another.  The  palmar  aspect  of  the  little  and  the  ulnar  side 
of  the  ring  finger  are  supplied  by  the  ulnar,  that  of  the  other  fingers 
by  the  median.  On  the  dorsum  of  the  baud  the  radial  and  ulnar  nerves 
supply  its  radial  and  ulnar  sides  respectively,  and  anastomose  with  one 
another.  The  dorsal  aspect  of  the  thumb  is  supplied  by  the  radial 
nerve  as  is  that  of  the  index  and  the  radial  side  of  the  middle  finger, 
as  far  as  the  second  phalanx.  The  dorsal  branch  of  the  ulnar  nerve 
supplies  the  dorsal  aspect  of  the  little,  ring  and  ulnar  side  of  the 
middle  fingers  as  far  as  the  second  phalanx.  In  some  cases  the  con- 
tiguous halves  of  the  dorsum  of  the  first  phalanx  of  the  ring  and  middle 
finger  is  supplied  by  the  radial  nerve  or  partly  by  the  radial  and  partly 
by  the  ulnar.  The  dorsal  aspect  of  the  second  and  third  phalanges 
of  the  four  fingers  are  supplied  by  branches  from  the  nerves  supplying 
their  palmar  surfaces. 

The  occasional  apparently  contradictory  results  of  nerve  lesions  are 
due  to  the  above  mentioned  variation  (on  the  ring  and  middle  fingers) 
and  to  the  anastomoses  between  the  nerves  on  the  dorsal  and  palmar 
surfaces  of  the  hand.  Thus  the  loss  of  sensation  is  often  quite  slight 
in  comparison  to  the  area  supplied  and  the  same  facts,  and  not 
"  immediate  union,"  probably  explain  the  cases  where  sensation  has 
returned  within  a  few  hours  after  suture  of  one  of  the  nerves. 

Motor  Nerve  Supply. — The  ulna  supplies  the  interossei,  adductor 
pollicis,  inner  head  of  the  flexor  brevis  poUicis  and  the  two  inner  lum- 
bricales,  as  well  as  the  muscles  of  the  hypothenar  eminence  and  the 
inner  half  of  the  flexor  profundus.  Hence  paralysis  of  the  ulnar  \sfol- 
loired  by  inability  to  adduct  the  thumb  (adductor),  to  flex  the  last 
phalanx  (profundus)  or  the  first  (interossei)  of  the  two  inner  fingers, 
or  to  extend  their  last  two  phalanges  (interossei).  The  latter  two 
fingers  are  therefore  held  in  the  position  of  extension  of  the  first  pha- 
lanx (common  extensor)  and  flexion  of  the  second  phalanx  (flexor  sub- 
limis).  The  muscles  of  the  hypothenar  and  ulnar  part  of  the  thenar 
eminence  are  jiaralyzed  and  become  atrophied. 

As  the  median  nerve  supj)lies  the  rest  of  the  long  flexors  and  those 
thumb  muscles  not  supplied  by  the  ulnar,  and  also  the  two  outer  lum- 
bricales,  its  paralysis  {^followed,  by  inability  to  flex  the  second  phalanx 
of  all  fingers,  the  last  phalanx  of  the  middle  and  index  fingers,  to  flex 
or  abduct  the  thumb,  to  pronate  the  hand  and  to  flex  the  wrist,  except 
by  means  of  the  flexor  carpi  ulnaris.  The  thumb  is  held  adducted 
and  extended.  Flexion  of  the  first  phalanges  with  extension  of  the 
last  two  can  be  performed  in  all  fingers  by  means  of  the  interossei. 

On  the  dorsum  of  the  hand  the  extensor  tendons  are  united  together 
by  connecting  slips  so  that  it  is  difficult  to  extend  one  without  the 
neighboring  finger.  The  index  finger  can  be  extended  alone  most 
readily,  next  the  little  finger,  for  they  are  joined  by  only  one  band  to 


PLATE    XXir. 


FIG.  52. 


Cutaneous  nerve  supply  of  the  upper  limb,  ventral  aspect. 

(W.   Keiller.) 


PLATE    XXII 

FIO.  63. 


Cutaneous  nerve  supply  of  the  upper  limlD,  dorsal  aspect. 

(W.   Keiller.) 


DISLOCATION  OF  THE  FINGERS.  199 

the  tendon  of  the  neighboring  finger.  The  ring  finger  is  extended 
alone  with  the  most  difficulty.  The  extensor  tendons  serve  the  place 
of  posterior  ligaments  for  the  three  joints  of  the  fingers.  When  the 
last  two  phalanges  alone  are  flexed,  the  first  is  steadied  by  the  extensor 
tendons  so  that  in  paralysis  of  the  latter  this  movement  is  not  possible. 
When  a  finger  is  torn  out  it  takes  with  it  one  or  more  tendons,  most 
often  the  flexor  profundus  tendon  if  only  one  is  avulsed. 

Felon  or  wMtlow  is  an  inflammation  usually  commencing  on  the 
palmar  aspect  of  the  terminal  phalanx,  in  the  soft  parts,  tendon 
sheaths  or  periosteum.  However  it  begins,  unless  it  is  promptly 
incised,  it  is  /iaUe  to  extend  to  the  synovial  sheath  of  the  tendon  or  to 
the  periosteum.  The  latter  is  readily  attacked  as  it  is  not  covered  by 
the  tendon  sheath  beyond  the  base  of  the  terminal  phalanx.  As  the 
result  of  the  involvement  of  the  periosteum  the  bone  often  necroses, 
but  usually  only  the  terminal  part  for  the  base,  which  is  an  epiphysis 
not  uniting  with  the  shaft  till  about  the  eighteenth  year,  is  protected 
by  the  insertion  of  the  flexor  profundus  tendon.  When  the  synovial 
sac  is  involved  the  abscess  extends  to  the  end  of  the  sac  opposite  the 
head  of  the  metacarpal  bone,  except  in  case  of  the  thumb  or  little 
finger  in  which  it  may  extend  into  the  palm,  beneath  the  annular  liga- 
ment and  up  into  the  wrist,  etc.  (see  p.  196). 

Bones  and  Joints. — In  fracture  of  the  metacarpal  bones  but  little 
displacement  is  allowed  as  they  are  splinted  to  the  neighboring  bones 
by  the  interosseous  muscles.  The  carpometacarpal  joints  of  the  first 
three  fingers  allow  of  but  little  motion,  that  of  the  little  finger  and  es- 
pecially that  of  the  thumb  allow  more  free  motion.  The  preservation 
of  these  joints  is  of  great  importance  to  the  usefulness  of  the  hand. 
Under  all  circumstances  as  much  of  the  thumb  as  possible  and  a  por- 
tion of  the  fingers  or  hand,  to  oppose  it,  should  be  saved,  to  preserve 
the  forceps  or  grasping  function  of  the  hand. 

Dislocations  of  the  metacarpophalangeal  and  interphalangeal 
joints  arc  coiiiiuDii.  Dislocation  of  the  first  phalanx  of  the  thumb  back- 
ward is  the  nioHi  important  on  account  of  its  common  occurrence  and 
the  frequent  difficulty  in  its  reduction.  The  latter  has  been  explained 
in  many  ways ;  the  button-holing  of  the  head  of  the  metacarpal  bone 
between  the  two  sets  of  muscles  which  center  in  the  sesamoid  bones, 
the  entanglement  of  the  long  flexor  tendon  around  the  neck  of  the 
metacarpal  bone,  the  intervention  of  the  anterior  glenoid  ligament  be- 
tween the  two  joint  surfaces,  etc.  The  latter  explanation  is  thought  by 
Farabreuf  to  cover  most  cases.  The  f/lenoid  lif/amcnt  is  torn  from  the 
metacarpal  bone,  to  which  it  is  loosely  attached,  but  remains  fixed  to 
the  phalanx  and  is  carried  back  with  it.  If  now  the  thumb  is  straight- 
ened, as  it  may  be,  and  traction  is  made  in  this  position  the  muscles 
attached  to  the  sesamoid  bones  pull  the  ligament  back  and  if  the 
phalanx  is  brought  back  into  place  by  traction,  the  glenoid  ligament 
lies  between  the  joint  surfaces  with  its  anterior  face  apj>lied  to  the  head 
of  the  metacarpal  bone.  In  any  case  traction  in  the  straightened  posi- 
tion should  never  be  employed  in   reduction  for  fear  of  ciianging  a 


200  THE   UPPER  EXTREMITY. 

simple  into  a  "  complex  dislocation,"  bat  rather  traction  in  the  hyper- 
extended  position.  According  to  Stimson  the  resistance  to  reduction 
is  due  to  the  torn  edges  of  the  anterior  ligament  drawn  closely  across 
the  metacarpal  bone  behind  its  head.  This  condition  is  frequently 
found  on  arthrotomy  performed  to  reduce  the  dislocation,  and  a  slight 
nicking  of  the  tense  edge  makes  reduction  easy. 

As  it  is  important  to  know  from  wJticJi  spinal  nerves  the  various 
nerves  of  the  arm  spring  and  the  muscles  supplied  by  them  are  inner- 
vated, for  the  purpose  of  diagnosis  of  nerve  injuries  of  the  upper  limb, 
the  following  table  is  added. 

Nerves. — Suprascapular  nerve  and  circumflex,  5,  6,  C;  posterior 
thoracic  (nerve  of  Bell)  and  musculocutaneous,  5,  6,  7,  C;  internal 
cutaneous  and  ulnar,  8,  C,  1,  D.;  lesser  internal  cutaneous  (nerve  of 
Wrisberg),  1,  D.;  musculospiral,  5,  6,  7,  8,  C;  median,  6,  7,  8,  C, 
and  1,  D.;  nerve  to  rhomboids,  5,  C;  nerves  to  subscapularis  and  teres 
major  (upper  and  lower  subscapular),  5  and  6,  C;  nerve  to  latissimus 
dorsi  (middle  or  long  subscapular),  7  and  8,  C. 

The  entire  hrachialplcxns  may  be  ruptured  or,  more  commonly,  torn 
away  from  its  attachments  to  the  cord,  or  one  or  more  of  its  cords, 
primary  divisions  or  branches  may  be  torn,  stretched  or  compressed. 
The  cutaneous  distribution  of  the  nerves  of  the  arm  is  shown  in  the 
accompanying  cuts. 


CHAPTER   III. 

THE    THORAX. 

I.     THE    THORACIC    WALLS. 

Shape  and  Size. — The  (uhilt  f/iora.r,  covered  bv  the  soft  parts, 
appears  conini/,  with  its  base  above  and  its  apex  below  and  flattened 
from  before  backwards.  Its  circumference  at  the  apex  of  the  axilla  is 
considerably  greater  in  the  male  than  that  at  the  level  of  the  nipple  or 
at  the  base  of  the  xiphoid  process.  In  the  fenw.le  the  circumference 
at  the  nipple  is  nearly  as  great  as  that  at  the  axilla  and  the  latter  is 
considerably  less  than  the  similar  measurement  in  the  male.  //;  flie 
pldhUical  the  upper  circumference  is  less  than  the  lower  (Hirtz).  The 
senile  thorax  is  narrowed  above  and  lengthened  so  as  to  be  conical  with 
the  base  below.  This  is  due  to  a  sinking  of  the  front  of  the  ribs,  due 
to  the  relaxed  tone  of  the  muscles.  //(  the  Jaius  it  is  flattened  later- 
ally, the  antero-posterior  diameter  being  the  greater.  In  the  infant  at 
birth  the  thorax  is  short,  nearly  circular  on  cross  section  and  conical, 
with  its  base  below.  These  differences  in  the  infant  are  due,  respec- 
tively, to  the  more  horizontal  position  of  the  ribs,  the  absence  of  the 
angles  of  the  ribs  and  the  greater  size  of  the  liver,  as  compared  with 
the  lungs. 

The  rcrticfil  diainctcr  of  the  posterior  wall  is  over  twice  that  of  the 
anterior  wall  in  the  median  line  (31.5  cm.  to  15.5  cm.)  and  the  verti- 
cal diameter  of  the  side  of  the  thorax  is  longer  than  that  of  the  poste- 
rior wall.  The  Jwif/Jit  of  the  thorax  increases  with  that  of  the  body 
but  not  proportionally,  the  tran,werse  diameter  increases  less  and  the 
(iiifcro-jHtsfcrior  (Jidiiictcr  still  less.  The  greater  height  of  the  bodv  is 
largely  due  to  the  length  of  the  lower  extremities.  However  a  too 
small  circumference  of  the  thorax  in  a  tall  subject  is  thought  to  indi- 
cate a  predisposition  to  phthisis.  In  the  Prussian  army  those  whose 
chest  circumference  is  less  than  half  the  body  height  are  regarded  as 
narrow-chested  and  predisposed  to  tuberculosis  unless  the  chest  is 
widened  by  drill.  The  thorax  of  the  female  is  relatively  smaller  than 
that  of  the  male,  is  less  flattened  and  more  rounded.  The  tiro  h(ilrej< 
of  the  thorax  i\V(}  usuaWy  loisi/iniiietriral,  \hc  right  measuring  more  (1  to 
1 1  cm.),  owing  to  the  greater  use  of  the  right  side. 

When  the  soft  parts  covering  it  have  been  removed  the  thorax  is 
seen  to  be  conical  in  shape  with  the  apex  above.  Hence  the  lung  ca- 
pacity is  not  indicated  by  the  breadth  of  the  shoulders  but  rather  by  the 
size  of  the  base  df  the  neck. 

Abnormal  and  Pathological  Forms  of  the  Thorax. — Occupation 
may  atl'ect  the  sliape  as  by  the  pressure  of  tools  depressing  the  ster- 

201 


202  THE  THORAX. 

num  and  flattening  the  thorax.  Corsets  may  so  press  in  the  lower 
ribs  as  to  make  the  thorax  spindle-shaped,  or  even  smaller  below  than 
above.  In  pigeon  breast  the  sternum  and  costal  cartilages  are  pro- 
truded in  relation  to  the  ribs,  like  the  sternum  of  a  bird.  It  occurs 
especially  in  rickety  children,  in  whom  the  long  bones  are  not  prop- 
erly ossified,  particularly  at  their  epiphyseal  junction,  as  at  the  costo- 
chrondral.  In  such  a  case  there  is  often  obstruction  in  the  respira- 
tory passages,  due  to  adenoids  or  hypertrophied  tonsils,  so  that  in 
inspiration  the  air  can  not  enter  the  chest  fast  enough  to  make  the  air 
pressure  within  equal  to  the  atmospheric  pressure  without  the  thorax. 
Hence  the  weakest  part,  or  that  along  the  costo-chondral  line,  is 
pressed  inward,  making  the  sternum  relatively  prominent.  In  rickets 
the  enlargement  of  the  ends  of  the  ribs  along  this  line  is  often  pal- 
pable and  sometimes  visible,  receiving  the  name  of  "  rickety  rosary." 

Two  opposite  pathological  types  of  thorax  may  be  distinguished. 
The  emphysematous  type  or  the  type  of  permanent  inspiration  is  like  that 
seen  in  pulmonary  emphysema.  The  chest  is  barrel-shaped,  enlarged 
in  circumference  but  shortened  vertically.  As  it  is  in  the  position  of 
inspiration  at  all  times  the  capacity  of  the  chest  can  not  be  much 
increased.  An  approach  to  this  type  is  normal  as  adult  life  advances. 
The  type  of  permanent  expiration  or  the  phthisical  typ)C  (habitus  j)aralyt- 
icus)  is  the  opposite  of  the  above.  The  chest  appears  flattened  and 
lengthened.  It  may  predispose  to  phthisis  or  be  the  result  of  it.  The 
upper  part  of  the  thorax  is  especially  contracted. 

Again  in  anterior  and  lateral  curvatures  of  the  thoracic  spine  the 
thorax  is  deformed.  In  anterior  curvature  of  the  spine  (usually  the 
result  of  Pott's  disease)  the  sternum  is  thrust  forward  and  the  ribs 
are  more  oblique,  approaching  the  pelvis  so  that  the  free  ribs  overlap 
the  iliac  crests.  In  lateral  curvature  the  ribs  on  the  convex  side  of 
the  curve  are  more  separated  from  one  another  than  normal,  those  on 
the  concave  side  more  pressed  together  and  sometimes  so  depressed  as 
to  touch  or  even  overlap  the  iliac  crests.  Owing  to  the  rotation  of  the 
vertebrae  the  ribs  on  the  convex  side  bulge  posteriorly  on  account  of 
the  prominence  of  their  angles,  and  the  scapula  is  carried  back  with 
them,  making  a  "hump"  on  that  side.  On  the  concave  side,  usually 
the  left,  the  front  of  the  chest  is  abnormally  prominent.  As  a  result 
of  pleuritic  or  pericardial  effusions,  aneurism,  tumors,  etc.,  the  tJiora.v 
may  become  protruded  and  it  may  become  sunken  in  from  retraction  of 
an  adherent  lung,  etc.  Such  protrusions  and  retractions  may  involve 
a  part  or  the  whole  of  one  half  of  the  thorax. 

The  internal  configuration  of  the  thorax  is  somewhat  heart-shaped 
owing  to  the  forward  projection  of  the  vertebral  bodies,  wliich  renders 
the  internal  sagittal  diameter  but  1  cm.  more  than  one  half  the  same 
measurement  externally.  Owing  to  the  backward  projection  of  the 
angles  of  the  ribs  and  the  fact  that  the  line  of  gravity  descends  in  the 
cord  of  the  backward  curve  of  the  thoracic  vertebrae  there  is  nearly 
as  much  space  within  the  thorax  behind  the  line  of  gravity  as  there  is 
in  front  of  it.     Hence  the  erect  position  is  easily  maintained  without 


LANDMARKS  OF  THE  THORACIC   WALLS.  203 

the  excessive  muscular  action  which  is  necessary  in  animals  in  which 
these  conditions  do  not  prevail.  Furthermore,  in  the  human  sul)ject, 
the  backward  projection  of  the  angles  of  the  ribs  on  either  side  to 
about  the  level  of  the  vertebral  spines  renders  possible  the  supine  posi- 
tion, which  is  not  possible  in  animals,  as  in  them  the  spines  project 
mesiallv  without  the  corresponding  lateral  projection  of  the  ribs. 

The  thorax  is  bounded  //(  front  by  the  sternum,  costal  cartilages 
and  the  spaces  between  them,  laferaUy  by  the  ribs  and  intercostal 
spaces,  behind  by  the  thoracic  vertebrae  and  the  posterior  ends  of  the 
ribs  and  intercostal  spaces.  The  bony  thorax  rorcr.s  several  of  the  ab- 
dominal viscera  in  addition  to  the  thoracic,  hence,  besides  the  thoracic 
cavity  proper,  it  bounds  part  of  the  abdominal  cavity,  the  two  being 
separated  by  the  obliquely  placed  diaphragm  (see  p.  212).  The  latter 
therefore  forms  the  convex  floor  of  the  thoracic  cavity  proper.  The 
(ipiccx  of  f/ic  hinfjx  and  pleural  cavities  extend  through  the  small 
superior  aperture  of  the  thorax,  as  well  as  the  trachea  and  oesophagus 
and  the  vessels,  nerves  and  muscles  which  pass  between  the  neck  and 
thoracic  cavity.  This  superior  aperture  connects  the  neck  and  thoracic 
cavity.  It  is  formed  bi/  the  first  ribs,  first  thoracic  vertebra  and  the 
top  of  the  sternum,  is  kidney-shaped,  and  slanted  slightly  downward 
from  behind  forward.  It  nietmires  2^  inches  from  behind  forward 
and  4^  transversely. 

To  assist  in  the  topography  of  the  chest  we  distinguish  certain 
vertical  lines  in  addition  to  the  median  line,  /.  e.,  the  .sfcnial  line  along 
the  side  of  the  sternum,  the  mammary  line  through  the  nipples,  the 
axillary  line  midway  between  the  anterior  and  posterior  axillary  lines, 
which  are  drawn  through  the  lower  ends  of  the  anterior  and  posterior 
axillary  folds,  and  the  xcapnlar  line  drawn  through  the  inferior  angle 
of  the  scapula.  The  parasternal  line  is  midway  between  the  sternal 
and  mammary  lines  and  the  costoclavicular  line  connects  the  sterno- 
clavicular joint  with  the  tip  of  the  eleventh  rib. 

Landmarks  of  the  Thoracic  Walls. — In  i\\Q  median  line  anteriorly 
the  top  of  the  sternum  corresponds  to  the  cartilage  between  the  second 
and  third  thoracic  vertebra3,  the  junction  of  the  manubrium  and  body 
of  the  sternum  is  indicated  by  a  readily  palpable,  prominent,  trans- 
verse ridge  which  is  continuous  with  the  second  costal  cartilages. 
This  is  the  easiest  and  most  reliable  point  to  start  from  in  counting 
the  ribs.  It  corresponds  to  the  lower  part  of  the  fourth  thoracic 
vertebra.  The  junction  of  the  body  and  cnsiform  process  of  the  ster- 
num is  readily  palpable  as  a  ridge,  for  the  cnsiform  is  at  a  deeper 
level  than  the  sternal  body.  This  junction  corresj)onds  to  the  articu- 
lation of  the  seventh  costal  cartilage  with  the  sternum,  and  to  the 
ninth  thoracic  vertebra  behind.  It  is  also  on  a  level  with  the  lowest 
point  of  the  fifth  rib. 

Laterally  the  ni])j>le  lies  on  a  level  with  the  anterior  end  of  the  fourth 
rib  (Hyrtl),  or  in  the  finirth  space,  tiearly  one  inch  external  to  the  costal 
cartilages.  The  virgin  breast  covers  the  ribs  from  the  third  to  the  sixth. 
The  lowest  point  of  the  seventh  rib  (the  junction  of  the  rib  and  costal 


204  THE  THORAX. 

cartilage)  lies  in  the  mammary  line.  The  costochondral  junction  of 
the  ribs  above  the  seventh  lie  internal  to  this  line,  that  of  the  lower 
ribs  extci-nal  to  this  line,  in  an  oblique  line  extending  downward  and 
outward.  The  lower  border  of  the  pectoralis  major  corresponds  to  the 
fifth  rib,  the  first  visible  i-.jrration  of  the  serratus  magnus  to  the  sixth 
rib.  Fosferior/i/  the  scapula  covers  the  ribs  from  the  second  to  the 
seventh  (sometimes  the  eighth).  Owing  to  the  obliquity  of  the  ribs 
we  find  in  a  sagittal  section  in  the  mammary  line  that  the  first  rib  in 
front  corresponds  to  the  fourth  rib  behind,  the  second  to  the  sixth, 
the  third  to  the  seventh,  etc.,  each  rib  below  the  first  in  front  corre- 
sponding to  the  fourth  one  lower  in  the  series  behind. 

The  Layers  of  the  Thoracic  Wall, — The  skin  over  the  sternum  is  a 
favorite  locality  for  keloid  (/rouiJis.  Gummata  are  also  often  found  in 
the  soft  parts  covering  the  sternum,  especially  the  periosteum.  The 
subcutaneous  tissue  of  the  thoracic  wall  may  be  the  seat  of  extensive 
einplnisciiKt  in  some  fractures  of  the  ribs  or  in  perforating  wounds  of 
the  thorax. 

The  sternum  is  very  variable  in  lemjih  and  is  often  not  in  propor- 
tion to  the  height  of  tlie  body.  I  have  seen  the  sternum  10|  inches 
long  in  a  man  of  average  height.  In  women  the  sternum,  and  espe- 
cially its  body,  is  relatively  shorter  than  in  men.  The  holes  or  clefts  in 
the  lower  part  of  the  sternum,  due  to  defects  in  its  development  from 
two  lateral  halves,  may  give  pus  an  entrance  to  or  an  exit  from  the 
mediastinum.  After  a  median  division  of  the  sternum  the  two  halves 
may  be  retracted  so  as  to  expose  the  great  vessels  in  the  mediastinum 
for  ligation.  It  may  be  trephined  to  open  mediastinal  abscess  or  for 
pericardial  paracentesis. 

The  sternum  may  be  frdctured  by  direct  violence,  as  by  the  violent 
contact  witii  the  chin,  or  by  indirect  violence,  as  by  the  traction  of  the 
muscles  when  the  body  is  forcibly  bent  backward.  The  fracture  is 
usually  transverse  and  occurs  most  often  at  or  near  the  juncture  of  the 
manubrium  and  body,  near  the  narrowest  part  of  the  bone.  The  body 
of  the  sternum  with  the  ribs  is  commonly  displaced  forward.  The 
lesion  is  often  a  di.sloc<dion  in  whole  or  in  part  through  the  joint  between 
the  manubrium  and  body.  In  old  age  when  this  joint  is  ossified  the 
tendency  to  fracture  is  increased  by  making  the  chest  more  rigid. 
Fracture  of  the  sternum  is  not  common  owing  to  the  elasticity  of  the 
ribs  and  costal  cartilages  Avhich  support  it,  the  elasticity  of  the  sternum 
which  is  formed  of  two  parts  articulated  together  at  a  slight  angle,  and 
the  soft  cancellous  character  of  the  bone.  The  cancellous  structure 
accounts  for  its  being  often  attacked  by  caries  and  for  its  ready  absorp- 
tion from  the  pressure  of  an  aneurism. 

The  tip  of  the  ensiform  cartilage  may  bend  forward  or  backw^ard. 
The  ensiform  often  presents  median  apertures  and  it,  as  well  as  its 
articulation  with  the  sternum,  may  become  ossified  in  advanced  age. 
The  costal  cartilages  by  their  ehifiticity  increase  the  resistance  of  the 
sternum  and  ribs  to  injury.  When  they  become  ossijied  in  advanced 
age  the  ribs  and   sternum  are  more  exposed  to  fracture.     They   in- 


FRACTURE  OF  THE  RIBS.  205 

crease  in  oh/i<juitt/  from  the  third  down,  and  in  l<n(/th  down  to  the 
seventh.  When  the  ribs  are  raised  in  inspiration  the  costal  cartilages 
are  raised  and  l)ecome  more  horizontal.  This  throws  the  ribs  outward, 
increasing  the  transverse  diameter  of  the  thorax.  Wiion  insj)irati(»n 
is  completed  their  rcsilicnri/  brings  them,  and  with  them  the  ril)s,  into 
their  normal  position  so  that  quiet  expiration  requires  no  muscular 
action.  At  the  border  of  the  sternum  only  the  first  two  or  three 
interspaces  between  the  costal  cartilages  are  wide  enough  to  operate 
through,  as  in  ligature  of  the  internal  mammary  artery.  Below  this 
the  spaces  are  so  narrow  that  resection  of  the  cartilages  is  necessary  to 
expose  the  parts  beneath. 

The  ribs  increase  in  ohllquity  from  above  downwards.  They  increase 
in  U'iK/th  as  far  as  the  seventh,  and  thence  they  decrease.  The  raishu/ 
of  the  ribs  in  insi)iration  shortens  the  thorax  but  increases  the  antero- 
posterior and  the  transverse  diameters.  The  latter  diameter  is  also  in- 
creased by  the  throwing  out  of  the  ribs  at  the  side,  in  the  rotation  that 
occurs  on  an  axis  passing  through  their  two  articulations.  This  rota- 
tion accounts  for  all  the  movements  of  the  ribs. 

The  ribs  are  unequally  exposed  to  injury.  The  upper  ribs,  first  and 
second,  are  protected  by  the  overlying  pectoral  muscle  and  the  clavicle, 
the  lower  or  false  ribs  by  their  mobility,  due  to  their  long  cartilages, 
etc.  Hence  it  is  the  ribs  in  the  middle  of  the  series,  fourth  to  eighth, 
that  are  most  often  fract u re fl.  In  advanced  age  the  ribs  are  more 
liable  to  fracture,  owing  to  the  ossification  of  the  cartilages. 

Fracture  may  be  due  to  direct  or  indirect  violence,  most  often  to  the 
former.  It  may  also  be  due  to  muscular  violence  as  in  coughing,  partu- 
rition, etc.;  but  in  such  cases  the  ribs  are  probably  pathologically  weak- 
ened. Indirect  fractures  are  due  to  some  excessive  pressure,  such  as 
being  run  over.  This  tends  to  increase  the  curve  of  the  ribs,  by  press- 
ing together  their  extremities,  until  they  break,  theoretically  near  the 
middle  of  their  curve  but  practically  in  their  anterior  or  posterior 
thirds.  Such  violence  usually  fractures  more  than  one  rib  and  is  liable 
to  injure  the  viscera  as  well.  Theoretically  the  ends  should  project 
outward  toward  the  skin,  but  practically  we  find  that,  owing  to  the 
thick  periosteum  and  the  intercostal  muscles  which  l)ind  the  ribs  firmly 
together,  displacement  of  the  ends  does  not  occur  to  any  great  extent, 
especially  if  only  one  rib  is  fractured.  Hence  there  is  rarely  any  de- 
formifi/  unless  several  consecutive  ribs  are  fractured.  For  the  same 
reason,  and  the  intraperiosteal  character  of  many  fractures,  crepitus 
and  false  motion  are  often  not  to  be  elicited.  It  is  probably  true 
however  that  injury  of  the  lung  by  the  fragments,  though  it  may  occur 
in  indirect  fracture,  is  less  common  than  in  direct  fractures,  in  which 
the  lesion  is  beneath  the  blow  and  the  fragments,  if  ilispUurd  at  all, 
tend  to  be  driven  inward,  lacerating  the  pleura  and  lung.  In  l)oth 
forms  of  fracture  the  side  of  the  chest  injured  is  strapped  to  lessen  the 
movements  of  the  ribs  on  that  side. 

Notwithstanding  the  constant  movement  at  the  articulations  of  the 
ribs  they  are  singularly  free  from  disease,  and  dislocation  is  very  rare. 


206  THE  THORAX. 

Resection  of  one  or  more  ribs  is  practiced  for  necrosis,  drainage  of  an 
enipvema  or  in  the  Estlander  or  Schede  operation  for  chronic  empyema. 
In  resection  the  periosteum  is  incised  and  separated  from  the  rib,  /.  e., 
the  rib  is  resected  si(hi,criosfea//i/.  In  this  way  we  avoid  injury  to  the 
jileura,  which  is  separated  from  the  ribs  by  the  periosteum  and  the  cndo- 
thordcic  f((.sci(i  lining  the  chest  cavity.  The  intervoMdl  vessc/.s  and 
iierves,  in  the  grooves  behind  the  lower  border  of  the  rib,  are  also 
avoided  for  they  lie  behind  tiie  periosteum.  (Fig.  54.)  Resection  of  an 
inch  or  so  of  rib  is  done  to  allow  more  free  drainage  than  is  secured 
in  the  narrow  intercostal  spaces.  The  seventh  rib  or  the  rib  above  or 
below  it  is  usually  selected.  As  the  ribs  form  a  firm  arch  there  is  no 
opportunity  for  retraction  of  the  thoracic  wall  to  obliterate  the  cavity 
of  a  chronic  empyema  and  the  lungs  are  bound  down  and  can  not 
expand.  The  Estlander  and  Schede  operations  meet  this  difficulty  by 
resecting  several  inches  of  a  number  of  consecutive  ribs  over  the  cavity. 
The  arch  of  the  ribs  is  thus  broken  and  both  ends,  as  well  as  the  inter- 
vening soft  parts,  may  sink  in  and  help  to  close  the  cavity  beneath. 

The  intercostal  spaces  are  narrower  behind  than  in  front,  in  expi- 
ration than  in  inspiration  and,  in  lateral  inclination  of  the  thorax,  on 
the  side  toward  which  it  is  inclined  than  on  the  opposite  side.  The 
third  space  is  the  widest  and  next  in  order  the  second,  first,  fourth, 
etc.  Any  of  the  first  five  spaces  will  admit  the  index  finger.  The 
coiifrnf.s  of  the  intercostal  spaces  include  the  external  and  internal 
intercostal  muscles,  covered  externally  by  a  thin  fascial  layer  and  in- 
ternally by  the  endothoracic  fascia  and  separated  from  one  another  by 
a  layer  of  cellular  tissue  in  which  the  intercostal  vessels  and  nerves 
lie.  (Fig.  54.)  Between  the  endothoracic  fascia  and  the  pleura  is  a 
loose  subpleural  cellular  layer.  Pus  from  disease  of  the  thoracic  verte- 
bne  or  the  posterior  i)art  of  the  ribs  may  work  around  in  the  intercostal 
spaces  and  apjx-ar  even  as  far  forward  as  the  sternum. 

Vessels  of  the  Thoracic  Wall. — The  aorta  and  superior  intercostals 
supj)ly  intercostal  arteries  for  each  space.  Between  the  vertebne  and 
the  angles  of  tlie  ribs  the  intercostal  vessels  pass  more  horizontally 
than  the  ribs  till  they  reach  the  cover  of  the  lower  border  of  the  ribs 
near  the  angles.  In  crossing  this  part  of  the  intercostal  spaces  they 
give  off  smaller  branches  which  pass  to  and  along  the  upper  margins 
of  the  ribs,  and  they  are  exposed  to  injury  by  incisions  or  paracente- 
sis. Similarly  in  the  anterior  third  of  the  intercostal  spaces,  where 
they  anastomose  with  branches  from  the  internal  mammary  artery, 
they  abandon  the  protection  of  the  ribs  and  are  more  or  less  exposed. 
But  here,  owing  to  their  small  size,  their  injury  is  not  as  serious  as 
posteriorly  where  a  fatal  hemorrhage  may  result.  Hence  incision  and 
j/tirarrnfr.si.s  are  to  be  avoided  posteriorly  and  anteriorly  and  practiced 
more  at  the  sides.  As  the  vessels  lie  much  nearer  the  pleura  than  the 
surface  they  are  likely  to  bleed  into  the  pleural  cavity  when  wounded 
unless  the  wound  is  very  freely  open  superficially.  It  is  remarkable 
that  the  intercostal  vessels,  lying  in  such  close  contact  with  the  ribs, 
are  almost  never  injured   in   fractures  of  the  ribs.     This  is  explained 


PLATE    XXIV 


FIG.  S4. 


iNTERCOSTAL    VE! N 
.NTERCOSTAL    ARTERVt" 
INTERCOSTAL    NERVeL 

INT. INTERCOS 

TAL    FASCIA 

INT.    INTERCOS- 

TA  L    MUSCLE 

PLEURA 


_^ SUPERFICIAL    FASCIA 

>u\     .  EXT.    INTERCOSTAL 

FASCIA 
EXT.     INTERCOSTAL 

MUSCLE 


—  PERIOSTEUM 


Vertical  section  of  the  sixth  intercostal  space  at  the  junction 
of  its  posterior  and  middle  thirds.     (Tillaux.) 


THE  INTERCOSTAL  NERVES.  207 

by  the  protection  afforded  by  tlie  periosteum  and  the  fact  that  ihe 
fragments  are  rarely  displaced.  Owing  to  the  protection  of  the  rii)s, 
in  the  greater  part  of  their  course,  the  intercostal  arteries  are  seldom 
wounded,  but  if  wounded  they  are  difficult  to  secure  without  injury  to  the 
pleura.  Paracentesis  may  be  done  with  care  in  any  space  within  the 
limits  of » the  ph-ura  were  fluid  can  be  diagnosed.  It  is  usually  ])cr- 
formed  in  the  sixth,  seventh  or  eighth  spaces  and  midway  between  the 
axillary  lines,  where  the  overlying  muscles  are  thin,  or  near  the  ])os- 
terior  axillary  line,  or  just  outside  the  angle  of  the  scapula,  where  the 
latissimus  dorsi  must  be  punctux'ed.  Especial  care  must  be  taken  in 
the  lower  spaces,  like  the  ninth  in  the  posterior  axillary  line,  not  to 
puncture  the  diaphragm.  The  needle  or  trochar  is  entered  near  the 
upper  border  of  the  rib,  to  avoid  the  main  intercostal  vessels,  and  in 
inspiration,  for  the  spaces  are  then  wider.  The  same  rules  apply  to 
incision.^,  which  however  can  be  made  in  the  lowest  spaces  with  greater 
safety  than  puncture,  as  they  are  not  made  blindly. 

The  intercostal  veins  accompany  the  arteries,  lying  above  them. 
Those  in  the  upper  six  or  seven  spaces  anastomose  with  the  branches 
of  the  axillary  vein.  (Braune.)  The  subcutaneous  veins  of  the 
thorax  form  an  anastomosis  between  the  axillary  and  the  femoral 
veins,  usually  through  the  superficial  epigastric  veins  (see  the  veins  of 
abdominal  wall). 

The  internal  mammary  artery  runs  a  finger's  breadth  from  the 
sternal  margin  behind  the  cartilages  and  interspaces.  It  is  .^(qjd rated 
from  flic  pleura  in  the  upper  two  spaces  by  the  endothoracic  fascia, 
which  is  here  thicker  than  elsewhere,  and  in  the  succeeding  four 
si)aces  by  the  triangularis  sterni  muscle.  As  it  is  a  vessel  of  some 
size  serious  or  fatal  hemorrhage  may  follow  its  injury,  and  the  bleed- 
ing is  most  likely  to  occur  internally  into  the  pleural  cavity.  As 
wounds  of  this  artery  are  uncommon  its  ligation  is  seldom  called  for 
but  may  be  done  in  one  of  the  three  or  four  upper  spaces.  Below  this 
the  spaces  are  so  narrow  as  to  require  resection  of  the  cartilages.  The 
third  space  is  preferable  as  this  is  wider  in  front  than  the  fourth  and 
the  pleura  is  protected  by  the  intervention  of  the  triangularis  sterni 
and  not  merely  by  the  endothoracic  fascia,  as  in  the  second.  On 
either  side  of  the  artery,  especially  mesially,  we  may  find  sternal 
lymph  nodes. 

The  intercostal  nerves  (or  anterior  divisions  of  the  thoracic  nerves) 
lie  below  the  arteries  in  their  course  behind  the  lower  border  of  the 
ribs,  though  they  are  at  first  above  them  in  the  upper  four  spaces. 
They  ■'<ujtjj/i/  the  costal  ])leura  as  well  as  the  skin  over  the  greater  part 
of  the  abdomino-thoracic  region,  so  that  pain  over  the  upper  part  of 
the  abdomen  may  be  due  to  pleurisy  or  to  pressure  on  the  nerves  by 
pleural  collections  of  fluid,  thoracic  tumors,  caries  of  the  lower  thoracic 
vertebra?,  etc.  The  htteral  rufdiieoiis  />r<nielies  perforate  the  thoracic 
wall  at  the  digitations  of  the  serratus  magnus  and  the  external  ab- 
dominal oblique.  The  lateral  cutaneous  branch  of  the  second  nerve 
crosses  the  axilla  (Fig.  43)  to  end  in  the  skin  of  the  inner  and  back 


208  THE  THORAX. 

part  of  the  arm  {iidcrcodo-hiuncral  nerve)  where  pain  may  be  felt  in 
pleurisy  of  the  upper  part  of  the  pleura  or  from  pressure  on  the  nerve 
in  axillary  suppuration  or  in  enlargement  of  the  axillary  lymph  nodes. 
The  intercostal  nerves  supply  both  the  intercostal  and  the  abdominal 
muscles  (see  also  nerves  of  abdominal  muscles).  It  should  be  remem- 
bered that  the  skin  over  the  upper  part  of  the  thorax  is  also  supplied 
by  the  superficial  descending  branches  of  the  cervical  plexus.  As  the 
posterior  divisions  of  the  thoracic  nerv^es  descend  a  considerable  dis- 
tance before  ending  in  the  skin  (Griffith),  the  line  of  anmsthesia  in 
fracture  of  the  thoracic  spine  and  the  line  of  pain  and  cutaneous  erup- 
tion in  herpes  zoster  is  horizontal  and  not  oblique. 

The  superficial  lymphatics  (above  the  level  of  the  umbilicus)  enter 
the  axillary  nodes.  The  deeper  lymphatics  in  the  intercostal  spaces 
run  in  two  sets,  the  deeper  ones,  just  beneath  the  pleura,  pass  forward 
to  the  sternal  nodes  along  the  internal  mammary  artery  ;  the  more 
superficial  ones  pass  backward,  through  small  nodes  at  the  back  of  the 
intercostal  spaces,  and  enter  the  thoracic  duct. 

The  Breast. 

The  Breast  {inammfi')  at  birth  and  up  to  puberty  is  alike  undeveloped 
in  both  sexes.  A  slight  secretion  of  a  colostrum-like  fluid,  with  evi- 
dences of  inflammation,  may  sometimes  occur  in  the  newborn  and  in 
boys  at  the  time  of  puberty.  Very  rarely  the  breast  is  well  devel- 
oped and  functionally  active  in  men. 

The/(7/io/c  bread  though  it  develops  much  at  puberty  does  not  reach 
its  full  functional  decelopment  until  the  end  of  pregnancy  and  during 
lactation.  After  lactation  the  breast  returns  to  its  former  condition 
until  again  stimulated  by  a  subsequent  pregnancy.  After  the  meno- 
pause the  breast  atrophies  and  at  this  time  is  quite  likely  to  be  attacked 
by  cancer. 

The  virgin  breast  is  hemispherical,  extendiucj  between  the  third  and 
sixth  ribs  and  between  the  sternal  and  anterior  axillary  borders.  Its 
circumference  is  not  quite  circular  but  presents  three  cusps,  one  toward 
the  sternum  and  two  tow^ards  the  axillary  line,  one  above  and  one 
below\  After  repeated  pregnancies  the  breast  becomes  more  flabby 
and  pendent,  so  that  its  position  it  not  a  reliable  landmark.  In 
certain  black  races,  as  in  the  Basutos,  it  is  flask-shaped  and  may  even 
be  flung  over  the  shoulder  or  beneath  the  axilla,  so  that  the  infant 
may  suckle  on  the  back. 

The  breast  (Fig.  55)  lies  upon  the  pectoralis  major  muscle,  slightly 
overlapping  it  onto  the  scalenus  anticus  muscle  below.  The  superficial 
fascia  of  the  region  splits  to  enclose  and  support  it,  and  sends  fibrous 
processes  to  connect  the  several  lobes  together.  Fibrous  trabecuke  con- 
nect the  gland  with  the  overlying  skin  and  more  loosely  with  the 
underlying  pectoral  fascia.  The  enclosing  fascia  is  rich  in  fat,  which 
thus  comes  to  lie  in  front  and  ])ehind  the  gland  and  between  its  lobes. 
Except  during  lactation,  and  oftentimes  then,  the  size  of  the  mamma  is 
largely  due  to  the  relative  amount  of  this  fat,  which  gives  the  breast, 


THE  BREAST. 


209 


with  its  ten  to  sixteen  lobes,  its  smooth  and  uniform  contour  and  elastic 
consistency.  Hence  the  large  size  of  the  breast  is  no  indication  of  good 
nursing  qualities  but  often  the  reverse,  the  fat  being  developed  at  the 
expense  of  the  gland  tissue.  During  lactation  and  in  conditions  of 
emaciation  the  fat  is  largely  absorbed,  so  that  the  gland  feels  more  dis- 
tinctly lobular.  Posteriori}/  the  mamma  is  loosely  connected  with  the 
pectoral  fascia  by  loose  connective  tissue  which  may  enclose  large  lymph 

Fig.  55. 


FIRST 
RIB 


B 
TORALIS 
NOR 

^COSTALES 
TH  OF  PEC- 
ALIS     MAJOR 

B 


ISSUE 
AL    PLANE 
PLE 


Right  breast  in  sagittal  section,  inner  surface  of  outer  segment.    (Geekish,  after  Testct.) 


spaces,  the  so-called  submammary  bursa.  This  is  one  of  the  sites 
selected  for  injection  of  hot  normal  saline  solution  in  shock  or 
septicajraia. 

Xornially  the  breast  should  be  iaov<il>h'  in  all  directions  on  the  pec- 
toral muscle,  the  failure  of  such  mobility  indicates  deep  extension  of 
the  growth  in  cancer  of  the  breast.  This  mobility  may  be  tested 
after  the  muscle  is  made  firm  by  its  contraction.  At  the  same  time 
the  breast  moves  somewhat  Avith  the  movement  of  the  muscle,  hence 
the  arm  should  be  held  at  rest  in  inflammation  of  the  gland. 
14 


210  THE  THORAX. 

It  is  most  important  to  remember  that  small  glandular  extensions 
may  pass  from  the  base  of  the  gland  to  and  even  through  the  pectoral 
fascia  so  as  to  lie  upon  or  in  the  muscle.  It  follows  that  every  operation 
of  excision  of  the  breast  for  cancer,  to  be  thorough,  should  remove  this 
fascia  and  the  surface,  if  not  the  entire  thickness,  of  the  underlying 
pectoral  muscle.  Similarly  the  fibrous  trabecn/re  [suspcnsori/  U<j(imenis 
of  Cooper),  which  connect  the  gland  with  the  skin,  may  contain  true 
glandular  tissue  (Stiles),  hence  no  overlying  skin  should  be  left  in 
excision  for  cancer. 

The  over/i/ing  .sJcin,  except  that  of  the  areola,  should  be  freely  mov- 
able, but  in  abscess  or  advanced  carcinoma  it  may  beome  adherent,  and 
in  some  cases  of  the  latter  it  is  infiltrated  with  small  nodules  of  carci- 
noma. In  lactation  or  in  cases  of  carcinoma  the  large  and  numerous 
subcutaneous  veins  are  often  very  plainly  visible.  The  skin  of  the 
areo/d  and  nipple  is  fatless,  pigmented,  very  thin  and  sensitive,  and 
adherent  to  the  parts  beneath.  Besides  highly  developed  papillse  the 
skin  of  the  nipple  contains  numerous  sebaceous  glands  whose  secretion 
protects  the  nipple  from  the  saliv^a  of  the  infant  and  guards  it  from  fis- 
sures. The  latter  occur  most  often  in  the  groove  between  the  nipple 
and  the  areola  where  none  of  these  glands  open.  The  tubercles  of 
Montgomery  in  the  skin  of  the  areola,  which  are  enlarged  in  pregnancy 
and  lactation,  represent  accessory  milk  glands  rather  than  sebaceous 
glands,  though  cndrrijo/ogicani/ the  hreast  represents  modified  sebaceous 
glands. 

Beneath  the  skin  of  the  nipple  and  areola  are  jjale  nmsch'  fibers^  both 
circular  and  radiating,  which  act  as  a  sphincter  on  the  lacteal  ducts 
traversing  the  nipple.  By  their  contraction  a  part  of  the  areola  is 
drawn  up  into  the  nipple,  thus  lengthening  and  erecting  the  latter, 
which  is  not  really  an  erectile  body.  The  lacteal  ducts,  one  for  each 
lobe  of  the  gland,  after  enlarging  into  a  spindle-shaped  ampulla  or 
reservoir  beneath  the  areola,  converge  to  and  traverse  the  nipple  to 
open  separately  by  fine  orifices  {h  mm.)  near  its  tip. 

Besides  ordinar\^  eczema  of  the  nipple  the  latter  may  be  the  seat  of 
a  chronic,  superficial,  reddened,  finely  granular,  raw  condition  known  as 
Paget' s  disease  of  the  nipple  which  results  in  epithelioma  of  the  lacteal 
ducts.  By  a  contraction  of  the  lacteal  ducts,  or  of  new  connective 
tissue  about  them,  in  scirrhous  cancer,  the  nipple  maybe  retracted  so  as 
to  present  a  depression  instead  of  a  projection. 

The  nipple  averages  half  an  inch  in  /engtii,  lies  a  little  below  and 
internal  to  the  center  of  the  gland  and  points  outward.  In  the  virgin  it 
corresponds  to  the  fourth  interspace  (or  fifth  rib)  four  inches  from  the 
median  line,  but  its  position  is  very  variable  after  pregnancy  or  in  old 
age.  In  some  cases  it  is  depressed  below  the  surface  so  as  to  prevent 
lactation.  The  consistency  of  the  breast  is  fir)n  without  being  hard. 
It  is  not  entirely  uniform  in  all  parts,  but  if  any  part  is  distinctly  hard 
it  is  pathological. 

Abscess  of  the  breast  is  not  uncommon  during  lactation  and  is  usu- 
ally due  to  an  infection  carried  by  the  lympViatics  from  a  fissure  or 


THE  LYMPHATICS  OF  THE  BREAST.  211 

eczema  of  the  nipple  or  areola.  It  may  occur  in  three  f<ifuations,  (1)  in 
the  fatty  connective  tissue  superficial  to  the  breast,  (2)  in  the  breast 
tissue  itself  or  its  interlobular  tissue,  and  (3)  in  the  loose  submararaar}' 
connective  tissue.  It  occurs  most  often  in  the  breast  tissue  and  one 
or  more  lobes  or  the  entire  organ  may  be  involved.  Incisions  to  ojien 
mammary  abscess  should  raditde  from  the  nipplr  io  avoid  damage  to  the 
lacteal  ducts. 

The  blood  supply  of  the  mamma  comes  mainly  from  the  lonf/f/iora- 
cic  (irtcni  (external  mammary),  which  follows  the  outer  border  of  the 
pectoralis  major,  also  from  the  second,  third,  fourth  and  fifth  per- 
forating intercostal  branches  of  the  internal  mammary  artery  and  in 
addition  from  the  corresponding  aortic  intercostals  and  perhaps  from 
tiie  acromiothoracic.  The  /t//(.s-  follow  the  same  course.  These  arte- 
ries and  veins  are  divided  in  excision  of  the  breast. 

The  lymphatics  are  of  special  importance  as  it  is  through  them  that 
metastatic  infection  occurs  in  carcinoma  of  the  breast.  The  superficial 
or  subcutaneous  and  the  deep  or  glandular  set  of  lymphatics  unite  in 
a  plexus  beneath  the  areola.  The  principal  outlet  is  by  two  or  three 
large  vessels  which  pass  along  and  beneath  the  external  border  of  the 
pectoralis  major  to  the  pectoral  group  of  the  axillary  nodes  (see  lym- 
phatics of  axilla).  The  fird  tiro  nodes  which  those  vessels  enter,  and 
consequently  the  first  to  be  affected  by  metastatic  growth  in  cancer  of 
the  breast,  usually  lie  on  the  third  rib  on  the  serration  of  the  serratus 
magnus.  From  these  the  infection  spreads  to  other  axillary  nodes  and 
the  subclavian  nodes.  Hence  we  see  the  necessity  of  eomplde  removal 
of  the  oxilkiry  nodes  and  contents  in  any  operation  for  carcinoma. 
From  the  inner  part  of  the  gland  vessels  also  pass  through  the  inter- 
costal spaces  to  the  sternal  nodes,  along  the  internal  mammary  artery, 
and  thus  reach  the  mediastinal  nodes  whence  indirectly  the  liver, 
pleura  and  lungs  may  become  involved.  As  the  superficial  lym- 
phatics of  the  inner  part  of  the  breast  may  cross  the  median  line  and 
enter  the  nodes  in  the  oj)posite  axilla,  the  involvement  of  the  latter  is  a 
possibility,  and  actually  occurred  in  one  case  reported  by  v.  Volkman. 

As  the  mamma  is  xnppUed  by  the  cutaneous  branches  of  the  second, 
third,  fourth  and  fifth  intercostal  nerves,  abscess  or  other  painful  affections 
of  the  breast  may  cause  pain  referred  to  the  side  or  back  of  the  thorax 
(intercostal  trunks),  the  region  over  the  scapula  (posterior  divisions  of 
thoracic  nervas)  or  down  the  arm  (intercostohumeral  branch  of  the  sec- 
ond intercostal).  Pain  shooting  up  the  neck  is  probably  along  the 
supraclavicular  branch  of  the  cervical  plexus  which  reaches  the  upper 
part  of  the  gland  and  also  communicates  with  the  second  intercostal. 
Sarcoma  of  the  breast  may  develop  from  the  connective-tissue  stroma 
of  the  gland,  carcinoma  from  the  glandular  elements. 

Abnormalities. — Small  siii,i,liinentarii  (/lands  are  often  present 
around  or  near  the  mamma  and  may  be  the  starting  point  of  many 
tumors.  Occasionally  additional  mammcv  or  nipples  exist,  sometimes 
in  the  axilla  but  more  often  (90  per  cent.)  below  the  regular  glands, 
verging  toward  the  median  line  so  as  to  follow  the  course  of  the  inter- 


212  THE  THORAX. 

nal  mammary  and  deep  epigastric  vessels.  They  may  even  occur  in  the 
groin.  The  occurrence  of  these  is  explained  by  reversion  or  atavism. 
Absence  and  imperfect  development  of  the  breasts  are  rare  and  usually 
associated  with  absence  or  arrested  development  of  the  sexual  organs. 
The  nipples  on  each  breast  may  be  double  or  even  triple  or  again  they 
may  be  wanting. 

The  Diaphragm. 

The  diaphragm,  situated  at  the  junction  of  the  superior  third  with  the 
inferior  two  thirds  of  the  trunk,  forms  the  floor  of  the  thoracic  cavity 
and  the  roof  of  the  abdomen.  It  is  not  a  single  but  a  double  or  bi- 
lateral muscle,  with  a  central  tendon.  Its  muscular  fibers,  arranged 
peripherally,  may  be  divided  into  sternal,  costal  and  lumbar  (or  ver- 
tebral) portions.  Between  these  portions  the  muscle  fibers  may  be 
wanting  over  a  greater  or  less  space,  so  that  the  serous  or  subserous 
layers  on  either  side  come  together.  Thus  the  muscle  fibers  are  often 
wanting  (hiatus  diaphragmaticus)  betM'een  the  vertebral  part,  com- 
prising the  crura  and  the  fibers  from  the  arcuate  ligaments,  and  the 
costal  part,  favoring  the  passage  of  inflammation  or  pus  from  a 
perinephritic  abscess  into  the  pleural  cavity,  or  the  occurrence  of  a 
hernia.  Similarly  between  the  sternal  portion,  from  the  back  of  the 
xiphoid  cartilage,  and  the  costal  portion  on  either  side  are  (/ap-'<  devoid 
of  muscle,  covered  above  by  pleura  on  the  right  side  and  pericardium 
on  the  left.  Through  these  gaps  pass  the  superior  epigastric  arteries 
and  some  hepatic  lymphatics,  on  their  way  to  the  mediastinal  glands. 
Also  between  the  two  halves  of  the  sternal  (xi])hoid)  insertion  is  usu- 
ally a  gap  through  which  the  cellular  tissue  of  the  mediastinum  is  con- 
tinuous with  the  subperitoneal  connective  tissue,  and  through  this  gap 
inflammation  and  pus  may  pass  or  extend  from  the  mediastinum  to  the 
epigastric  region  or  vice  versa. 

Through  some  one  of  the  above  (/ops  diaphragmatic  hernia  either 
congenital  or  acquired  is  most  likely  to  occur.  In  the  former  variety 
one  of  the  gaps,  especially  the  xiphocostal,  may  be  congenitally  large 
or  a  portion  of  the  diaphragm  may  be  deficient.  The  ac(juired  form  is 
due  to  a  muscular  strain  or  external  violence.  It  may  be  suddenly 
acquired,  as  by  a  fall  or  blow,  in  which  case  there  is  likely  to  be  rup- 
ture of  the  peritoneum  and  hence  no  sac ;  or  gradually  acquired,  as  by 
straining,  coughing,  etc.,  when  a  sac  is  usually  present.  Almost  any 
of  the  abdominal  ri.^cera,  but  especially  the  stomach,  colon  and  omen- 
tum, form  the  contents  of  such  a  hernia  in  the  pleural  cavity.  The 
lungs,  owing  to  their  elasticity,  are  never  herniated  into  the  abdomen. 
Many  of  the  acute  acquired  cases  are  rapidly  fatal  and  often  are  not 
diagnosed  ante  mortem,  but  if  diagnosed  surgical  intervention  offers  the 
only  hope. 

The  fleshy  portion  of  the  diaphragm,  arising  in  an  oblique  line  from 
the  base  of  the  xiphoid  cartilage  to  the  last  rib  and  the  lumbar  verte- 
brae, passes  at  first  vertically  upward,  connected  with  the  inner  sur- 
face of  the  thorax  by  connective  tissue,  to  the  lower  limit  of  the  pleura 
(see  p.  215).     Thence  lined  above  by  pleura  it  is  separated  from  the 


THE  DIAPHRAGM.  2 13 

thoracic  wall  by  a  cleft-like  space  lined  by  ])leura  {coxfojjhrenic  Hinuis), 
into  which  the  lung  does  not  descend  in  deep  inspiration.  Thence 
{i.  c,  from  the  level  of  the  lower  border  of  the  lung)  the  diaphragm 
curves  upward  and  inward,  concave  inferiorly,  into  the  trefoil  central 
tendon.  Hence  in  the  lower  part  of  the  bony  thorax  a  wound  in- 
volves the  thoracic  wall,  diaphragm  and  peritoneal  cavity  ;  at  a  higher 
level  it  involves  the  thoracic  Mall,  pleural  cavity,  diaphragm  and  ])eri- 
toneal  cavity ;  still  higher  the  lung  intervenes  in  the  pleural  cavity. 
Unless  the  lower  part  of  the  pleural  cavity  is  filled  with  fluid  or  gas 
the  diaphragm  is  in  close  contact  with  the  chest  wall  below  the  lower 
border  of  the  lung,  a  fact  to  be  remembered  in  incisions  here. 

The  level  of  the  diapliragm  varies  between  ex-  and  inspiration.  The 
middle  portion  or  rciifrdi  tendon,  on  the  central  or  left  leaflet  of 
which  rests  the  heart,  stretches  from  the  base  of  the  ensiform  process 
nearly  horizontally  backward  to  the  vertebrae.  This  portion  moves 
sli(//itii/  in  respiration  (about  1  inch,  Sibson),  though  Hyrtl  thought  it 
stationary.  The  pericardium  and  heart  must  necessarily  follow  its 
movements,  hence  its  motion  is  slight.  The  dome,  or  hif/}test  point  of  the 
diaphragm,  reaches  the  /erel  of  the  fifth  cartilage  on  the  rir/Jd  side,  or 
one  inch  below  the  nipple,  on  tlie  left  the  breadth  of  a  cartilage  lower, 
the  presence  of  the  liver  making  the  right  side  higher.  In  early  life 
the  diaphragm  is  higher  than  given  above  and  it  is  lower  in  old  age. 
The  hei(/Jd  of  the  diaphragm  is  altered  hi/  pathological  conditions  in  the 
thoracic  and  abdominal  cavities.  Thus  it  is  lowered  in  pleural  or  peri- 
cardial extravasations  and  in  emphysema,  and  raised  when  extensive 
adhesions  exist  in  the  pleural  cavities  with  retraction  of  the  lung  or 
when  tumors,  fluid  or  meteorism  are  present  in  the  abdomen. 

As  to  the  three  openings  in  the  diaphragm,  the  aortic  opening  in  front 
of  the  twelftii  thoracic  vertebra,  lies  in  or  slightly  to  the  left  of  the 
median  line.  The  inner  portion  of  the  two  crura  which  arch  in  front 
of  the  aorta  to  form  the  aortic  orifice  is  fibrous,  so  that  the  contraction 
of  the  dia])hragm  does  not  cause  compression  of  the  aorta.  The 
wsopliageed  opening,  above  and  in  front  of  the  aortic  opening  and  to  the 
left  of  the  latter  and  the  median  line,  is  oval  and  surrounded  by  fleshy 
fibers.  It  lies  in  front  of  the  ninth  thoracic  vertebra.  Very  rarely 
the  oesophageal  opening  is  found  in  the  right  crus,  in  the  median 
line,  or  to  the  right  of  it.  I  have  found  this  condition  in  one  case  of 
gastrotomy,  ])reliminary  to  a  retrograde  dilatation  of  an  oesophageal 
stricture,  and  another  similar  case  has  been  recently  reported. 

The  ;>/<'(//■«  of  both  pleural  cavities  and  the  pericardium  are  closely 
connected  with  the  diaphragm,  the  ^''/wVo/zDo/f  more  loosely.  The  under 
surface  of  the  heart  resting  on  the  central  tendon  of  the  diaphragm 
explains  the  presence  of  the  heart  beat  in  the  epigastrium,  and  its  ex- 
aggeration in  hypertrophy  of  the  right  ventricle.  The  liver,  stomach, 
spleen,  pancreas,  kidneys  and  supraronals  are  in  contact  Avith  the  under 
surface  of  the  diaphragm,  the  lungs  and   heart  with  the  u]i])er  surface. 

The  diaphragm  is  supplied  by  the  phrenic  nerves  in  paralysis  of 
which  respiration  is  carried  on  almost  entirely  by  the  intercostals  and 


214 


THE  THORAX. 


the  epigastrium  sinks  instead  of  protruding  on  inspiration,  as  the  dia- 
phragm no  longer  pushes  the  abdominal  viscera  downward  and  for- 
ward. In  action  the  diaphragm  increases  the  vertical  diameter  of 
the  thorax  but  as  it  also  raises  the  lower  six  ribs  it  increases  the 
other  two  diameters  in  the  lower  part.  When  fixed  in  the  position  of 
inspiration  by  the  closure  of  the  glottis,  it  assists  the  abdominal  mus- 
cles in  expulsive  efforts,  defecation,  parturition,  etc.,  by  pressing  down 
the  abdominal  viscera  and  holding  them  there.  The  abdominal  vis- 
cera press  the  diaphragm  upward  in  the  supine  position,  hence  many 
patients  with  dyspnoea  breathe  better  in  the  sitting  posture. 

The  Pleura. 

The  pleura  of  each  side  is  a  large  serous  sac  or  lymph  f<pace  whose 

median  or  mediastinal  wall  is  invaginated  at  one  point  (the  root  of  the 

lungs)   by  the  lung  whose  outer  surface  it  covers  as  the  visceral  or 

pulmonary  pleura.     Normally  there  is  no  pleural  cavity,  the  opposing 

Fig.  56. 


RIGHT    INTER- 
LOB     INCISURE 


MEDIAN    LOBE 


LOWER    LOBE 


COSTO    PHRENIC 
SINUS 


COSTO-MEDI- 
ASTINAL  SINUS 


LEFT    SNTERLOB. 

INCISURE 
CARDIAC 
INCISURE 
COSTO-PERI- 

CARDIAL 

SINUS    , 
LINGULA 


LOWER    LOBE 


TRIANGULAR     AREA     OP  ""T.JJ*'"' 

PERICARDIUM     NOT 
COVERED   BY    PLEURA 

Position  of  tlic  lungs  and  pleurie  witii  reference  to  the  anterior  chest  wall.     (.Ioesskl.  ) 


MAMMARY 
LINE 


smooth,  inner  surfaces  of  the  pleura  being  in  contact  with  only  a  slight 
amount  of  fluid  between  to  diminish  friction.  Pathologically  the  pres- 
ence of  fluid  (serum,  pus)  or  air  may  make  a  cavity.  It  is  important 
to  know  the  limits  of  the  pleura  both  for  diagnosis  and  treatment. 


LIMITS  OF  THE  PLEURA.  215 

The  dome  of  the  pleura  is  completely  occupied  by  the  apex  of  the 
lung  and,  like  the  latter,  is  grooved  by  the  subclavian  artery  antero- 
internally,  hence  in  ligation  of  the  artery  the  pleura  is  in  danger  of 
injury.  The  pleural  dome  and  the  apex  of  the  lung  extend  into  the 
root  of  the  neck  5  cm.  (2  in.)  above  the  anterior  part  of  the  first  rib, 
but  never  above  its  neck,  and  1  to  3  cm.  above  the  clavicle  in  the 
upright  position,  but  scarcely  or  not  at  all  above  it  in  the  supine  posi- 
tion or  in  forced  inspiration,  in  which  positions  the  clavicle  is  elevated. 
Clinically  the  resonance  on  percussion  of  the  apex  extends  higher  above 
the  clavicle  than  its  actual  level.  The  dome  of  the  pleura  is  //(  re/atioa 
vi^ith  the  scaleni  medius  and  anticus  and  the  deep  layer  of  the  deep  cer- 
vical fascia.  //  //V.y  behind  the  inner  end  of  the  clavicle  and  the  sterno- 
mastoid  muscle  and  projects  into  the  base  of  the  posterior  cervical 
triangle. 

The  anterior  borders,  along  which  the  costal  and  diaphragmatic  por- 
tions of  the  pleura  meet  in  front,  extend  from  the  dome  downward  and 
inward  behind  the  sternoclavicular  joints  and  the  sternum  meetinr/  op- 
posite the  junction  of  the  manubrium  and  the  body  of  that  bone  a  little 
to  the  left  of  the  middle  line.  From  this  point  they  descend  vertically 
and  nearly,  or  sometimes  quite,  in  contact,  to  the  level  of  the  fourth  or 
fifth  cartilage  whence  they  diverge  to  reach  the  seventh  chondrosternal 
junction,  leaving  between  them  a  triangular  area  of  sternum  in  con- 
tact with  the  pericardium.  The  l<ft  pleura  below  the  fourth  cartilage 
passes  along  the  left  border  of  the  sternum,  or  at  most  the  inner  ends 
of  the  fourth  to  the  sixth  costal  cartilages,  but  does  not  bend  outward, 
as  does  the  cardiac  incisure  of  the  lung,  to  leave  the  pericardium  bare. 
Hence  under  normal  conditions  the  pericardium  cannot  as  a  rule  be 
punctured  through  an  interspace  without  traversing  the  pleura. 

The  lower  border  of  the  pleura,  along  which  the  costal  and  dia- 
phragmatic portions  meet,  reache.s  the  upper  border  of  the  seventh 
cartilage  at  the  side  of  the  sternum,  the  lower  border  of  the  seventh 
rib  in  the  mammary  line,  the  ninth  rib  in  the  axillary  line  and  the 
twelfth  rib  or  eleventh  thoracic  spine  at  the  side  of  the  vertebrse. 
It  may  extend  slightly  below  the  inner  end  of  the  twelfth  rib,  occa- 
sionally even  to  the  lower  border  of  the  first  lumbar  transverse  process 
(Pansch),  an  important  point  in  lumbar  incisions  to  reach  the  kidney 
(see  p.  282).  Although  the  left  pleura  may  extend  somewhat  loiver 
than  the  right,  owing  to  the  liver  on  the  right  side,  the  difference  in 
level  is  so  slight  that  clinically  it  is  not  worth  considering.  The 
posterior  border,  extending  between  the  neck  of  the  first  and  the  head 
of  the  twelfth  rib,  is  indicated  in  part  by  a  ridge  bounding  posteriorly 
the  groove  which  on  the  left  side  is  formed  by  the  aorta  and  on  the 
right  side  by  the  azygos  major  vein. 

Along  the  anterior  and  inferior  borders  the  lungs  do  not  reach  as 
far  as  the  pleune  but  leave  an  interval  or  siims  wiiere  two  layers  of 
parietal  pleura  are  in  contact.  The  costomediastinal  sinus,  or  that 
along  the  anterior  border,  is  filled  by  lung  in  inspiration  on  the  right 
side,  but  on  the  left  side,  opposite  the  cardiac  incisure  of  the  lung,  a 


216 


THE  THORAX. 


wide  interval  remains  in  the  fullest  inspiration,  corresponding  to  the 
area  of  cardiac  flatness,  where  the  heart  is  uncovered  by  lung. 

The  costophrenic  sinus,  along  the  lower  border  of  the  pleura,  is  never 
filled  on  the  deepest  inspiration.  The  extent  of  the  contact  of  the 
costal  and  phrenic  portions  of  the  pleura  varies  in  diifereut  parts  and 
on  inspiration  and  expiration,  and  corresponds  to  the  difference  of 
level  of  the  lower  borders  of  the  pleura  and  lung.  In  quiet  breath- 
ing this  sinus  measures  2  cm.  at  the  sternal  and  mammary  lines, 
2.5  cm.  near  the  vertebrae  and  6  cm.  in  the  axillary  line  (Luschka). 

Fig.  57. 


LEFT INTERLOB 
INCISURE 


RIGHT    INTERLOB. 
INCISURE 


LOWER    LOBE^ 


COSTO-PHRENIC 
SINUS  OF  PLEURA 


LEFT    SCAPULA 
LINE 


RIGHT  SCAPULA 
LINE 


Position  of  the  lungs  and  pleune  with  reference  to  the  posterior  chest  wall.     (Jokssel.) 

Pathological  fluids  first  collect  here  and  can  here  be  first  diagnosticated. 
The  presence  of  the  sinus  explains  the  fact  that  a  wound  may  penetrate 
the  pleura  and  the  diaphragm,  and  then  enter  the  peritoneal  cavity  or 
the  liver,  without  involving  the  lung.  Unless  we  are  sure  that  this 
sinus  is  full  of  fluid  it  is  not  safe  to  puncture  the  pleural  cavity  below 
the  lower  limit  of  the  lung,  though  an  incision  may  be  carefully  made 
at  the  lower  limit  of  the  pleura.  The  lower  limit  of  the  sinus  is  still 
quite  a  distance  above  the  lower  attachment  of  the  diaphragm  and  the 
costal  margin  (about  2|  inches  from  the  latter).  The  thin  diaphragm 
alone  separates  the  lower  end  of  the  pleurae  from  the  kidneys.  The 
pleura  is  said  to  descend  lower  in  the  child.  In  children  also  the 
thymus  separates  the  anterior  borders  of  the  pleurae  more  widely  than 


INFLAMMATION  AND  WOUNDS  OF  THE  PLEURA.  217 

in  tlie  adult.  The  thick  co.s/a/  pleura  is  so  connected  with  the  endo- 
thoracic  fascia  by  loose  connective  tissue  that  it  is  easily  stripped  up, 
while  the  diap/iragmatic  pleura  is  closely  adherent. 

Above  the  level  of  the  root  of  the  lung  the  mediastinal  pleura 
stretches  evenly  between  the  sternum  and  the  vertebne,  covering  the 
vessels  of  the  mediastinum.  Along  the  root  of  the  lung  the  parietal 
(mediastinal)  is  continuous  with  the  visceral  pleura.  Opposite  and 
below  the  root  of  the  lung  the  mediastinal  pleura  covers  and  is  closely 
attached  to  the  outer  surface  of  the  pericardium,  with  the  phrenic 
nerves  between,  hence  the  latter  may  be  affected  by  inflammation  of 
either  membrane.  The  attachment  to  pericardium  is  more  extensive 
on  the  left  side,  as  the  heart  projects  more  into  the  left  half  of  the 
thorax.  Behind  the  pericardium  the  mediastinal  pleura  on  either  side 
forms  a  triangular  fold  connected  with  the  posterior  border  of  the 
lungs  from  the  hilum  down,  6-8  cm.  in  length,  the  lif/ameiduin  latum 
2yulmo)ii.s.  Its  base  stretches  over  the  diaphragm,  w'hen  the  lung  is 
pulled  laterally,  and  is  free.  In  removing  the  lungs  the  broad  liga- 
ments as  well  as  the  roots  must  be  divided. 

The  thin  visceral  or  pulmonary  layer  of  the  pleura,  besides  covering 
and  being  closely  adherent  to  the  surface  of  the  lungs,  dips  down  into 
the  bottom  of  the  fissures,  both  surfaces  of  which  it  lines. 

In  pleurisy,  or  inflammation  of  the  pleura,  the  opposing  surfaces,  pul- 
monary and  parietal,  arc  congested  and  then  thickened  and  roughened 
by  cell  proliferation.  The  rubbing  together  during  inspiration  of  these 
roughened  areas  causes  the  friction  sounds  and  pain,  hence  the  chest  is 
strapped  in  pleurisy  to  prevent  the  movement  of  the  lungs.  As  the 
intercostal  nerves  supply  the  intercostal  and  other  respiratory  muscles 
as  well  as  the  costal  pleura,  the  patient  with  pleurisy  neither  will  nor 
can  draw  a  deep  breath  on  account  of  pain.  Adhexionti  may  form 
between  opposed  roughened  areas  of  the  pleura.  When  /?w/cZ  is  extrav- 
asated  this  first  accumulates  in  the  costophrenic  sinus,  or  posteriorly 
in  the  supine  ])osition.  If  the  fluid  is  excessive  the  lungs  are  pressed 
backward  and  inward  toward  the  hilum  and  the  costovertebral  groove. 
The  occasional  rapid  absorption  of  large  quantities  of  pleuritic  effusion 
is  explained  by  the  fact  that  the  pleura  is  a  large  lymph  space.  In  the 
cases  of  "pleurisy  with  ejf'usiou^^  running  a  longer  course  the  hyper- 
plastic thickening  may  be  very  marked  and  the  adhesions,  when  the 
fluid  is  removed,  may  be  very  extensive. 

In  ivounds  penetrating  the  pleura  air  may  enter  the  pleural  cavity 
causing  pueuiuotliorax.  If  the  oj)ening  is  free  the  elasticity  of  the 
lungs  causes  them  to  collapse  and  retract  toward  the  hilum  ;  if  the  open- 
ing is  not  free  the  respiratory  movements  may  force  the  air  into  the  sub- 
cutaneous tissues,  producing  subcutaneous  emphysema.  Owing  to  the 
close  contact  of  the  visceral  and  parietal  layers  of  the  pleura  the 
latter  can  scarcely  be  wounded,  except  in  the  sinuses,  without  wound 
of  the  former.  Emj)hysema  may  also  be  caused  by  a  rujitured  vomica 
or  by  a  wound  of  the  lung  such  as  is  sometimes  seen  in  fractured  ribs, 
the  air  coming  from  the  opened  bronchi,  etc.  (see  p.  205).     Some  non- 


218  THE  THORAX. 

penetrating  Avounds  may  also  cause  such  an  emphysema,  the  air  being 
drawn  in  during  one  movement  of  respiration  and  forced  into  the  tissues 
during  another,  the  valvular  nature  of  the  wound  preventing  its  escape. 
Hernia  of  the  lung,  through  a  wound  of  the  thoracic  wall,  can  only 
occur  when  the  lung  fails  to  collapse,  and  this  implies  that  the  glottis 
Avas  closed  at  the  time  of  injury,  or  that  extensive  adhesions  bound  the 
lung  to  the  chest  wall.  In  the  latter  case  the  adhesions  would  pre- 
vent hernia.  In  hconothora.v,  or  blood  in  the  pleural  cavity,  there  is 
usually  a  wound  or  lesion  of  the  lung,  but  the  blood  can  come  in  greater 
or  less  part  from  the  parietal  wound. 

The  Lungs. 

The  two  pyramidal-shaped  lungs  occupy  about  four  fifths  of  the 
thoracic  cavity  proper. 

Position. — Contained  in  the  two  pleural  sacs  their  apices  correspond 
in  position  to  the  domes  of  the  pleura  which  they  completely  fill.  From 
the  apices  of  the  lungs  the  anterior  borders  (Figs.  56  and  57),  which 
become  thin  and  sharp  about  4  cm.  below  the  apices,  descend  con- 
vergingly  behind  the  sternoclavicular  joints  and  nearly  meet  behind 
the  sternum,  opposite  the  second  cartilages.  Thence  they  descend 
vertically  to  the  level  of  the  fourth  cartilages.  In  infants  the  thymus 
separates  the  anterior  borders  more  widely,  the  right  lung  barely  reach- 
ing the  median  line  while  the  left  only  reaches  the  left  sternal  border 
(Symington).  From  the  level  of  the  fourth  cartilages  the  right  lung 
bends  slightly  outward  to  reach  the  upper  border  of  the  sixth  chondro- 
sternal  junction,  while  the  left  lung  curves  sharply  outward,  with  an 
external  convexity,  across  the  fourth  space  and  the  fifth  cartilage  and 
thence  back  to  the  inner  end  of  the  sixth  left  cartilage.  In  expiration 
this  "cardiac  incisure"  may  reach  to,  or  nearly  to,  the  apex  of  the 
heart,  which  is  covered  by  the  lingula.  It  forms  the  left  boundary  of 
the  area  of  cardiac  flatness  and  the  right  border  of  the  lingula  of  the 
left  upper  lobe. 

The  level  of  the  lower  border  (Figs.  56  and  57)  is  especially  im- 
portant for  the  diagnosis  of  certain  pulmonary  conditions.  In  quiet 
breathing  the  lower  border  is  at  the  upper  border  of  the  sixth  costal 
cartilage  in  the  sternal  line,  the  upper  border  of  the  seventh  rib  in  the 
mammary  line,  the  lower  border  of  the  seventh  rib  in  the  axillary  line, 
the  ninth  rib  in  the  scapular  line,  the  upper  border  of  the  eleventh  rib 
er  the  tenth  space  at  the  vertebrae.  It  will  thus  be  seen  that  the  level 
of  the  lung  at  any  line  except  the  sternal  is  the  same  as  the  level  of 
the  pleura  at  the  line  next  anteriorly  (see  p.  215).  The  left  lung  is 
said  to  be  longer  and  extend  lower  than  the  right  lung  but  the  differ- 
ence is  so  slight,  if  it  exists,  that  it  is  not  worth  considering  from  a  prac- 
tical clinical  standpoint.  In  deep  inspiration  the  lower  border  descends 
about  an  inch  and  a  half  (Godlee),  in  emphysema  it  is  permanently 
lower,  in  the  aged  it  is  one  half  to  one  intercostal  space  lower  and  in 
children  the  same  distance  higher  than  in  the  adult.  The  posterior 
border,  extending  from  the  neck  of  the  first  rib  to  the  eleventh  rib,  is 


THE  FISSURES  OF  THE  LUNG.  219 

usually  taken  to  be  the  rounded  part  occupying  the  costovertebral 
groove  but,  as  stated  above  (see  p.  215),  it  is  better  to  consider  it  the 
ridge  bounding  the  back  of  the  groove  for  the  aorta  on  the  left  and 
the  azygos  major  vein  on  the  right.  To  this  border  is  attached  the 
ligamentum  latum,  below  the  hilum,  Xormally  the  surface  of  the 
lung  is  everywhere  in  contact  with  the  parietal  j)leura,  which  thus  sup- 
ports it,  and  it  is  further  held  in  position  by  its  attachment  to  the 
mediastinum  by  means  of  the  root  of  the  lung  and  the  ligamentum 
latum. 

Relations. — The  concave  base  of  the  lung  resting  on  the  (Hftjj/n-df/ni 
is  only  separated  by  the  latter  and  its  serous  coverings  from  the  fhrloiu- 
inal  viscera  in  contact  with  it,  liver,  stomach,  spleen,  kidneys,  supra- 
renals.  Inflammation,  abscess  and  tumors  of  these  organs,  after  pene- 
trating the  diaphragm,  may  inv^olve  the  pleurie  and  lungs  and  vice  versa. 
On  jjcrcKssioit  we  distinguish  the  lower  border  of  the  lung  on  the  right 
side  by  the  contrast  between  the  pulmonary  resonance  and  the  liver 
dullness  below  it,  and  on  the  left  .side  by  the  less  marked  contrast 
between  the  tympanitic  resonance  of  the  stomach  and  the  pulmonary 
resonance.  Internally  the  licfirf  and  many  of  the  f/rcfif  ve.ssr/s  of  the 
mediastinum  are  in  relation  with  the  lungs.  The  greater  projection  of 
the  heart  on  the  inner  aspect  of  the  left  lung  inferiorly  makes  the  left 
lung,  and  especially  its  base,  narrower  than  the  right  and  accordingly 
its  bulk  and  weight  are  less.  The  left  lung  averages  twenty  ounces, 
the  right  lung  twenty-two  ounces  in  irciyld,  but  the  weight  may  be 
greatly  increased  by  disease.  The  subclavian  artery  grooves  the  fore 
part  of  the  upper  end  of  the  apex  in  a  transverse  direction. 

The  fissures  extend  deeply  toward  the  hilum.  The  fissure  (Figs. 
56  and  57)  which  separates  the  upper  from  the  lower  lobe  commences 
on  both  sides  at  the  posterior  border  three  inches  below  the  apex,  on  a 
level  with  the  third  thoracic  spine  or  the  inner  end  of  the  spine  of  the 
scapula.  Thence,  sweeping  around  the  convex  surface  of  the  lung,  it 
meets  the  lower  border  in  the  mammary  line  on  the  right  side,  and  at 
the  outer  end  of  the  sixth  cartilage  on  the  left  side.  On  the  right  side 
this  fissure  crosses  the  convex  surface  somewhat  lower  than  on  the  left 
and  from  about  its  middle,  or  where  it  crosses  the  posterior  axillary 
line,  a  second  fisxurc  (Fig.  56)  passes  nearly  horizontally  forward  to 
the  fourth  right  chondrosternal  junction,  separating  a  middle  lobe  from 
the  upper  lobe. 

Fosf/'riorhf,  practically  all  the  lung  above  the  level  of  the  inner  end 
of  the  spine  of  the  scapula  is  upper  lobe,  all  below  is  lower  lobe. 
Laterallji,  In  the  axilla rji  line,  all  the  lung  above  the  fourth  rib  on  both 
sides  belongs  to  the  upper  lobe,  while  on  the  left  side  all  below  belongs 
to  the  lower  lobe,  and  on  the  right  side  from  the  fourth  to  the  sixth 
rib  belongs  to  the  middle  lobe,  all  below  the  sixth  rib  to  the  lower 
lobe. 

Anteriorly,  in  t/ie  nvnnniary  line,  on  the  left  side  all  the  lung  above 
the  middle  of  the  fifth  space  belongs  to  the  upper  lobe,  all  below  to 
the  lower  lobe ;  on  the  right  side  all  above  the  fourth  rib  belongs  to 


220  THE  THORAX. 

the  upper,  all  below  to  the  middle  lobe.  We  thus  see  that  the  lower 
lobe  is  not  only  below  but  behind  the  upper  lobe.  These  points  are 
of  practical  importance  in  the  physical  examination  of  the  lungs, 
especially  when  pneumonia  or  tuberculosis  are  suspected,  for  in  the 
former  the  lower  lobe  and  in  the  latter  the  upper  lobe  are  most  often 
involved. 

The  apex  of  the  lung  is  a  favorite  site  for  phtiral  adhesions  and  for 
tubercular  lesions.  The  frequency  of  adhesions  may  be  accounted  for 
by  the  fact  that  the  apex  at  all  times  fills  the  dome  of  the  pleura  and, 
being  a  narrow  portion  of  lung  tissue,  its  motion  is  slight ;  and  by  the 
fact  that  the  apex  is  frequently  the  seat  of  lesions  which  may  lead  to  a 
pleurisy.  In  proportion  to  its  bulk  the  apex  probably  expands  as 
much  as  any  other  part  of  the  lung,  so  that  the  prevalence  of  tuber- 
cular lesions  here  is  not  to  be  accounted  for  by  the  stagnation  of  the 
air  current  in  this  part  (see  p.  221). 

The  concave  median  surface  presents  the  oval  fissure  or  hilum  where 
the  structures  contained  in  the  root  of  the  lungs  emerge  or  enter.  The 
upper  end  of  the  hilum  is  at  the  junction  of  the  upper  and  middle 
thirds  of  this  surface,  opposite  the  disc  between  the  fifth  and  sixth 
thoracic  vertebrse,  and  at  the  junction  of  the  anterior  three  fourths 
with  the  posterior  fourth  of  this  surface.  Hence  the  root  of  the  lung 
is  more  accessible  from  behind.  The  neighborhood  of  the  root  of  the 
lung,  on  account  of  the  large  vessels  here,  must  be  avoided  in  punctur- 
ing the  lung  with  a  needle  for  diagnosis.  This  may  be  safely  done 
over  the  greater  part  of  the  anterior  surface  to  the  depth  of  1 J  inches 
in  a  backward  and  outward  direction.  In  puncturing  the  apical  part 
from  in  front,  through  the  first  or  second  spaces,  remember  that  the 
internal  mammary  artery  is  a  finger's  breadth  from  the  sternum  and 
the  axillary  vein  is  3J  inches  from  the  middle  line  in  the  first  space 
and  4|  inches  in  the  second  space. 

The  color  of  the  lungs  changes  from  a  reddish  brown  in  the  foetus  to 
a  pinkish  white  at  birth,  owing  to  their  insufflation  with  air.  In  the 
((dull  they  are  slate-colored,  with  a  darker  mottling  of  certain  lobules, 
which  increases  with  age,  is  very  marked  in  coal  miners,  etc.,  and  is 
due  to  the  deposit  in  the  interlobular  tissue  of  carbonaceous  particles 
absorbed  by  the  lymphatics.  The  specific  gravity  of  the  lungs  is  nor- 
mally lighter  than  water  so  that  they  float,  but  in  certain  diseased 
conditions  (pneumonia,  etc.)  and  in  the  foetus  that  has  never  breathed 
they  sink.  This  fact  is  useful  medicolegaUy  to  determine  whether  an 
infant  was  still-born  or  born  alive.  If  the  child  has  breathed  the 
vjeif/Itt  of  the  lungs  also  increases  by  one  third  (on  account  of  the  access 
of  blood),  the  size  increases  and  the  eonsidency  is  altered  by  aeration. 

While  the  capacity  of  the  lungs  after  the  deepest  inspiration  aver- 
ages 5,000  cm.,  1,500  cm.  of  this  (residual  (dr)  can  not  be  expelled  by 
the  fullest  expiration.  The  total  capacity  minus  the  residual  air,  or 
3,500  cm.,  is  the  vital  capacity  of  the  lungs  and  is  liable  to  be  affected 
by  various  diseases  of  the  lungs.  In  quiet  breathing  1,500  cm.  of 
"reserve  air"  remain  after  expiration  in  addition  to  the  residual  air, 


PULMONARY  VESSELS  AND  BRONCHI.  221 

and  in  inspiration  only  500  cm.  are  Breathed  in,  leaving  1,500  cm.  of 
complciiicntdl  fiir  to  be  inspired  by  a  forced  inspiration. 

Vessels. — The  hronchial  rrs.srLs  supply  the  mechanism  of  the  lung,  or 
the  lung  stroma.  They  anastomose  to  some  extent  with  the  pulmonary 
vessels  and  so  may  be  of  service  in  stenosis  or  closure  of  the  pulmo- 
nary artery,  which  is  extremely  rare.  The  pulmonary  artery  in  its 
course  to  and  througli  the  lung  is  curved  with  an  vpvard  convcrifif. 
From  the  convex  surface  the  first  branch  given  oif  passes  to  the  upper 
lobe  and  apex.  Solid  particles  in  the  current  which  have  a  specific 
gravity  greater  than  the  blood  tend  to  hug  the  upper  wall  and  to  pass 
into  the  first  branch  given  off  from  this  part.  Thus  they  pass  into  the 
upper  lobe  and  apex.  This  is  the  probable  explanation  of  the  more 
frequent  occurrence  of  tuberculosis  in  the  apex,  especially  as  the  tuber- 
cles are  first  observed  in  the  walls  of  the  smaller  arteries  at  their  points 
of  bifurcation. 

When  a  branch  of  the  pulmonary  artery  is  plugged  by  an  embolus 
the  circulation  is  stopped  in  the  area  supplied  by  it.  This  is  called 
an  infarct  and  is  wedge-shaped  with  the  apex  at  the  plug  and  the  base 
on  the  surface  of  the  lung,  for  such  is  the  shape  of  the  area  supplied  by 
the  vessel,  whose  circulation  is  terminal.  If  such  an  embolus  is  infec- 
tive an  abscess  may  result.  Only  in  the  lung  can  the  embolus  come 
from  a  systemic  vein,  so  that  the  lung  is  a  frequent  seat  of  pysemic 
infarcts  and  abscesses. 

The  lymph  vessels  of  the  lung  empty  into  four  or  six  nodes  in  the 
root  of  the  lung  which  are  accessory  to  the  bronchial  nodes.  The  root 
nodes  are  black  from  the  pigment  absorbed  in  the  lungs.  They  are 
often  diseased,  and  thus  menace  the  neighboring  parts. 

In  the  bronchi  the  mu.scular  tissue  is  arranged  circularly  and.  by  its 
reflex  irritation  from  the  vagus,  as  in  indigestion,  or  by  direct  irrita- 
tion in  uric  acid  or  ursemic  conditions,  it  may  contract  suddenly  and 
give  rise  to  an  attack  of  f^pa.wiodic  (i.'<tlima.  In  chronic  intersititial pneu- 
monia the  pull  of  the  contracting  new  tissues  draws  apart  the  walls  of 
the  bronchi,  as  these  offer  less  resistance  than  the  retraction  of  the 
chest  wall.  Large  bronchial  cavities  {Iji'onchiert(ms)  are  thus  formed, 
in  which  the  fluid  collecting  is  liable  to  decompose  and  give  rise  to 
foetid  breath  and  expectoration. 

The  alveoli  of  adjacent  infundibula  were  formerly  thought  to  be 
independent,  but  by  corrosion  preparations  anastomoses  are  found 
between  them  and  even  between  those  in  adjacent  lobules.  In  vesic- 
ular emphysema  some  air  cells  are  distended,  others  are  blended  with 
one  or  more  adjacent  cells,  and  thus  the  oxygenating  capillary  area  of 
the  lung  is  diminished.  In  interlobular  emphysema  the  air  cells  burst 
and  allow  the  air  to  escape  into  the  pulmonary  connective  tissue. 

The  elasticity  of  the  lung  is  one  of  its  striking  and  important  fea- 
tures. It  assists  expiration,  is  one  of  the  factors  producing  pigeon 
breast  in  the  rachitic,  explains  the  fact  that  in  rujiture  or  wountl  of 
the  diaphragm  the  lung  is  never  herniated  into  the  abdomen,  and  it 
maintains  the  vault  of  the  diaphragm.     If  the  lung  is  wounded  within 


222  THE  THORAX. 

the  limits  of  a  pleural  adhesion  subcutaneous  emphysema  may  be 
produced  but  not  pneumo-  or  hemothorax.  AVhen  the  pleural  cavity  is 
opened  through  the  thoracic  wall,  or  through  the  lung,  the  atmospheric 
pressure  within  and  without  the  lung  is  equalized,  and  hence  it  retracts, 
owing  to  its  elasticity.  In  such  cases  we  have  a  sero-sanguinous  ex- 
travasation and  air  in  the  pleura  and  if  the  chest  wall  is  injured,  as  by 
a  fractured  rib,  subcutaneous  emphysema  is  likely  to  occur.  The 
gravity  of  icounds  of  the  lung  depends  largely  upon  the  hemorrhage, 
hence  they  are  more  serious  on  the  internal  surface  near  the  large  ves- 
sels. It  is  remarkable  that  the  air  in  pneumothorax  seldom  contains 
germs,  or  at  least  in  sufficient  number  to  infect  the  extravasation  of 
blood,  \younds  of  the  lung  cicatrize  rapidly  and  the  air  in  the  pleu- 
ral cavity  is  rapidly  absorbed.  Blood  expectorated  from  the  lungs  is 
necessarily  coughed  up  and  mixed  with  air,  hence  it  is  frothy  and 
bright  red.  It  is  also  alkaline,  while  that  retched  up  from  the  stom- 
ach is  acid  and  dark. 

The  Roots  of  the  Lungs  (Fig.  58)  contain  from  before  backwards 
pulmonaiy  vein,  artery  and  bronchus,  and  from  above  downward  artery, 
bronchus  and  vein.  On  the  right  side  however  there  is  an  eparterial 
bronchus  above  the  artery.  In  addition  the  roots  contain  bronchial 
arteries  and  veins,  lymphatics  and  four  to  six  nodes,  pulmonary  plexuses 
(anterior  and  posterior)  and  nerves,  and  connective  tissue,  the  whole  sur- 
rounded by  the  pleura  reflected  from  the  mediastinal  to  the  visceral 
layers,  except  below  whence  the  ligamentum  latum  pulmonis  stretches 
downward.  It  will  thus  be  seen  that  the  hi-onchu.s  lies  posteriorly  and 
between  the  other  parts  and  when  an  object  is  impacted  in  the  main 
bronchi  or  their  primary  divisions  they  may  best  be  reached  from  behind 
by  making  a  flap  opening  into  the  thorax  at  the  side  of  the  vertebrae  at 
the  level  of  the  fourth  to  the  seventh  ribs.  In  such  cases  the  relations 
of  the  roots  of  the  lungs  are  important.  On  the  right  side  the  azygos 
major  vein  is  behind  and  arches  above  it,  to  open  into  the  superior 
cava  ;  while  on  the  left  side  the  arch  of  the  aorta  is  above  and  the  de- 
scending aorta  and  oesophagus  behind  it.  On  both  sides  the  pneumo- 
gastric  nerv^e  and  the  larger  or  posterior  pulmonary  plexus  are  behind, 
and  the  phrenic  nerve  and  the  smaller  or  anterior  plexus  in  front.  Hence 
the  left  side  is  more  covered  by  important  relations  and  is  more  difficult 
to  reach,  but  according  to  some  the  pleura  is  retracted  with  more  diffi- 
culty on  the  right  side  so  that  the  latter  is  harder  to  reach.  The 
root  of  the  lung  measures  3  cm.  vertically  and  2  cm.  antero-posteriorly, 
the  right  root  is  larger,  the  left  longer. 

The  Thoracic  Portion  of  the  Trachea. 

This  c.rtend.s  from  the  episternal  notch,  at  the  level  of  the  disc 
between  the  second  and  third  thoracic  vertebrae,  to  its  bifurcation, 
opposite  the  fourth  or  fifth  thoracic  vertebra,  and  includes  about  half 
the  length  of  the  tube,  or  2^  inches.  It  lies  in  the  superior  medias- 
tinum between  the  two  pleural  sacs  and  the  vagus  nerves,  in  front  of 
the  oesophagus,  and  behind  the  remains  of  the  thymus  gland,  the  left 


PLATE    XXV. 


FIG.    58. 


Kpart. 
:.>!  oiichii.i 


Ptdm.y. 

ref«s     \  \       \ 


(I  real 
coroH.  cfii 


Foramen  for 
cesophagna 


Thoracic  contents  seen  ri'om  beliind.     (Joessel.) 


THE  PERICARBimf.  223 

innominate  vein,  the  innominate  and  left  carotid  arteries  and  the  trans- 
verse arch  of  the  aorta.  It  bifurcfdca  behind  the  lower  border  of  the 
aortic  arch  at  about  the  level  of  the  junction  of  the  first  and  second 
pieces  of  sternum,  or  of  the  inner  end  of  the  spine  of  the  scapula. 
Hence  abnormal  sounds  produced  at  the  tracheal  bifurcation,  or  in  the 
primary  bronchi,  can  best  be  heard  between  the  shoulders  at  this 
level.  Surrounding  the  bifurcation  of  the  trachea  are  twenty  to  thirty 
hroiicliUil  (i/iiip}i  iiodcs^  which  are  fref]Uontly  diseased  and  may  press 
upon  and  narrow  the  trachea  or  adhere  to  and  ulcerate  through  it. 
Stenosis  of  the  trachea  from  syphilitic  lesions  or  from  aneurisms  of  the 
aorta  or  the  great  vessels  are  apt  to  occur  at  the  upper  or  lower  ends 
of  the  trachea. 

Of  the  two  bronchi  the  rif/ht  is  the  larger,  so  that  the  dividing  ridge 
between  the  two  bronchi  lies  to  the  left  of  the  median  line  and  the 
trachea  seems  to  lead  more  directly  into  the  right  bronchus.  Hence, 
and  by  reason  of  the  greater  intake  of  air,  foreign  b<jdies  are  more 
likely  to  pass  into  the  right  bronchus  and,  as  we  have  already  seen, 
this  is  the  side  most  safely  exposed  from  behind.  Foreign  bodies  at 
or  a  little  below  the  bifurcation  of  the  trachea  may  often  be  removed 
by  forceps  introduced  through  a  low  tracheotomy  opening,  or  they 
may  be  sj)ontaneously  expelled  by  a  fit  of  coughing  through  the  open 
tracheal  wound  or  through  the  larynx.  In  other  cases  they  have 
ulcerated  through  the  bronchus  and  been  discharged  through  an  abscess 
at  the  back,  adhesions  having  shut  off  the  pleura ;  Mr.  Godlee  records 
a  case  where  a  head  of  rye  so  escaped. 

The  course  of  the  bronchi  is  toward  the  hind  part  of  the  lower 
surface  of  the  lung  (/.  e.,  behind  the  axis  of  the  lung).  Hence,  of  the 
ventral  and  dorsal  branches  given  off  by  the  bronchi  the  former  are 
much  the  larger.  The  right  stem  bronchus  is  slightly  curved  inward 
and  is  more  vertical  than  the  left,  which  is  displaced  laterally  by  the 
heart  and  takes  an  S-shaped  curve,  being  first  displaced  inward  and 
downward  by  the  aortic  arch.  The  relation  of  the  latter  explains  the 
pressure  of  aneurisms  on  this  part  of  the  left  bronchus.  The  right 
undivided  bronchus  averages  one  inch  in  /enr/th,  the  left  two  inches. 
The  latter  enters  its  lung  an  inch  lower  than  the  right,  opposite  the 
sixth  thoracic  vertebra. 

The  Pericardium. 
The  pericardium,  like  the  pleura,  is  a  closed  invaginated  sac.  But 
it  is  more  complicated  than  the  pleura,  for  instead  of  one  there 
are  seven  reflections  which  connect  the  parietal  and  visceral  layers 
and  form  more  or  less  complete  sheaths  around  the  great  vessels  at 
the  base  of  the  heart.  Between  these  sheaths  there  are  a  number  of 
pouches  or  sinuses,  of  which  the  largest  is  the  great  or  tran.-^rerse  sinus, 
between  the  auricles  behind  and  the  tubular  sheath  of  the  aorta  and 
pulmonary  artery  in  front.  An  encapsulated  effusion  may  occur  in 
this  sinus,  the  pressure  of  which  is  exerted  principally  upon  the  thin- 
walled  vena  cava  superior.     Sinuses  like  those  of  the  pleura  exist  only 


224  THE  THORAX. 

to  a  slight  extent  at  the  reflection  of  the  pericardium  from  the  dia- 
phragm. The  tubular  pericardial  sheath  common  to  the  aorta  and 
pulmonary  artery  is  the  only  complete  one  among  the  seven.  It 
covers  the  proximal  1|  inches  of  these  vessels,  which  is  therefore 
within  the  pericardial  sac.  The  parietal  layer  is  reinforced  externally 
bv  a  fibrous  layer  which  blends  with  the  outer  coat  of  the  great  vessels 
beyond  their  serous  investments  and  becomes  continuous  above  with 
the  deep  cervical  fascia. 

The  elasticity  of  the  parietal  pericardium  is  an  important  factor. 
It  allows  it  to  be  stretched  to  double  its  size,  so  as  to  contain  twelve  to 
eighteen  ounces  in  case  of  acute  pericardial  effusion,  or  even  up  to  three 
pints  in  chronic  cases.  It  is  only  when  the  pericardium  is  greatly 
distended  that  the  pressure  affects  the  heart  and  may  cause  a  fatal  re- 
sult. As  the  shape  of  the  pericardium  is  cone-  or  pear-shaped,  with 
the  base  below  on  the  diaphragm  and  the  apex  above,  this  is  the  shape 
of  pericardial  effusions,  while  in  cardiac  hypertrophy  or  dilatation  the 
long  diameter  is  directed  transversely.  In  pericardial  effusion  the 
dullness  reaches  beyond  the  apex  beat  or,  if  the  effusion  is  extensive, 
the  apex  beat  may  not  be  perceptible.  When  the  sac  is  but  partly  full 
the  fluid,  and  with  it  the  area  of  dullness,  may  shift  its  position  with 
that  of  the  body  and,  as  it  presses  upon  the  bronchi  in  the  reclining 
position,  the  patient  may  breathe  more  easily  in  the  upright  posture. 
By  exce.ssive  pericardial  effusion  the  lungs  are  pushed  aside  laterally, 
increasing  the  area  of  heart  dullness,  the  diaphragm,  liver  and  stom- 
ach are  displaced  downward  and  the  lower  two  thirds  of  the  ster- 
num and  the  corresponding  left  cartilages  and  spaces  are  bulged 
forward. 

Paracentesis  of  the  pericardium  is  usually  done  in  the  fifth  left 
space  one  inch  from  the  sternum.  If  a  point  nearer  the  sternum  is 
taken  there  is  danger  of  wounding  the  internal  mammary  artery, 
though  if  an  incision  is  used  and  not  a  puncture  we  may  go  close  to  the 
sternum.  Unless  the  pleura  has  been  pushed  aside  by  the  effusion  the 
trocar  will  puncture  two  layers  of  it  one  inch  from  the  sternum.  The 
puncture  may  also  be  made  in  the  sixth  left  space  with  less  danger 
of  wounding  the  heart.  Some  advise  puncturing  on  the  right  side  of 
the  sternum  in  the  fourth  or  fifth  space,  where  the  distended  peri- 
cardium also  bulges,  on  the  supposition  that  there  is  less  danger  of 
puncturing  the  heart  itself. 

Normally  the  pericardium  is  in  direct  relation  with  the  anterior 
parietes  (sternum)  only  (1)  over  a  small  area  at  its  upper  end  where  it 
is  reflected  onto  the  aorta  and  (2)  over  a  triangular  area  at  the  lower 
end  of  the  sternum  where  the  pleurae  diverge  and  where,  by  a  tre- 
phine opening,  the  pericardium,  uncovered  by  pleura,  may  be  reached. 
No  true  ligaments,  only  loose  connective  tissue,  bind  the  pericardium 
to  the  back  of  the  sternum.  Whereas  in  front  and  laterally  the  peri- 
cardium is  largely  covered  by  pleura,  the  phrenic  nerves  intervening 
laterally,  posteriorly  it  forms  the  anterior  boundary  of  the  posterior 
mediastinum  and  is  in  direct  relation  with  the  thoracic  aorta,  azygos 


HEART.  225 

veins,  thoracic  duct,  and  oesophagus,  on  which  pericardial  effusion  may- 
press,  especially  in  the  supine  position. 

Heart. 

On  opening  the  pericardium  in  front  we  see  the  anterior  or  sternocostal 
surface  of  the  heart  comprising  a  part  of  the  two  ventricles,  the  right 
auricle  and  its  appendage  and  the  tip  of  the  left  auricular  appendage. 
Of  these  parts  the  r'njld  voitrick'-  j)resents  the  greater  area,  hence  it  is 
most  often  wounded  in  wounds  of  the  heart.  The  under  surface  rests 
on  tlie  diaphragm  and  looks  also  somewhat  backward.  As  the  right 
ventricle  is  one  third  the  thickness  of  the  left  we  can  tell  the  two  apart 
by  tlie  feeling.  For  the  same  reason  the  inferior  border,  formed  of 
the  right  ventricle,  is  thin  (^iiiairjo  acidus),  the  left  border  is  thick 
(inargo  obtusus),  so  that  it  may  be  considered  a  surface  rather  than  a 
border.  The  left  ventricle  is  thinnest  at  the  apex  and  thickest  at  the 
junction  of  its  upi)er  and  middle  thirds.  The  anterior  and  posterior 
interventricular  grooves  meet  and  are  continuous  to  the  right  of  the 
apex,  and  lie  near  the  left  and  inferior  borders  respectively. 

Tlie  heart  lies  obliquely  behind  the  lower  two  thirds  of  the  sternum, 
from  the  ui)per  border  of  the  third  costal  cartilages  to  the  sterno- 
xiphoid  junction.  In  front  it  is  overlapped  by  the  pleuree,  except  behind 
the  lower  end  of  the  sternum  as  described  above  (p.  215),  and  by  the 
thin  margins  of  the  lungs,  except  for  the  area  between  the  pleuroe  and 
that  of  the  cardiac  incisure,  which  corresponds  to  the  area  of  cardiac 
flatness.  The  latter  corresponds  to  a  triangiihir  (trea  bounded  below 
b\'  the  lower  border  of  the  heart,  on  the  right  by  the  left  sternal  margin 
up  to  the  upper  border  of  the  fourth  cartilage,  and  on  the  left  by  a 
line  curved  outward  from  the  latter  point  to  the  lower  border  near 
the  apex.  A  circle  two  inches  in  diameter,  with  its  center  midway  be- 
tween the  nipple  and  the  sternoxiphoid  junction,  would  also  approxi- 
mately represent  this  area. 

The  anterior  or  sternocostal  surface  is  the  only  one  accessible  to 
clinical  investigation  by  percussion,  etc.  Besides  the  area  of  cardiac 
flatness  we  have  the  area  of  cardiac  dullncs>i  which  corresponds  to  that 
part  of  the  anterior  surface  overlapped  by  lung  and  sternum.  Owing 
to  the  modification  of  the  percussion  note  by  the  sternum  and  the  margin 
of  the  right  lung  the  right  border  of  the  heart  cannot  be  definitely 
determined.  As  the  heart  dullness  merges  into  that  of  the  liver  below, 
the  loirer  border  cannot  be  determined  by  percussion,  but  may  be  con- 
structed by  continuing  the  lower  border  of  the  right  lung  through  the 
sternoxiphoid  junction  to  the  apex  of  the  heart.  The  left  border  alone 
is  tolerably  accessible  to  percussion  and  by  this  we  determine  changes 
in  the  size  and  position  of  the  heart. 

Laterallij  the  heart  is  in  contact  with  the  lungs,  separated  by  the 
pericardium,  pleurte  and  phrenic  nerves.  It  encroaches  more  on  the 
left  side  of  the  cliest  and  the  left  lung,  so  that  two  thirds  of  the  heart 
are  on  this  side.  Only  the  right  auricle  and  a  small  part  of  the  left 
auricle  and  right  ventricle  are  on  the  right  side  of  a  median  vertical 
15 


226  THE  THORAX. 

plane.  The  auricles  lie  above,  behind  and  to  the  right  of  the  mass  of 
the  ventricles  and  correspond  to  the  sixth,  seventh  and  eighth  thoracic 
vertebrae.  But  between  the  heart  and  the  thoracic  spine  lies  the  pos- 
terior mediastinum,  containing  the  oesophagus,  thoracic  duct,  aorta  and 
azygos  veins. 

The  apex,  belonging  solely  to  the  left  ventricle,  is  directed  downward, 
forward  and  to  the  left  and  strikes  the  chest  wall  in  systole  in  the  fifth 
space  3^  inches  from  the  median  line,  or  two  inches  below  and  one  inch 
internal  to  the  nipple.  The  apf.i*  6e«^  may  be  likened  to  the  recoil  of  a  gun. 

Topography. — The  heart,  as  projected  onto  the  chest  wall,  may  be 
mapped  out  as  a  triangidar  figure,  whose  upper  truncated  angle  repre- 
sents the  base  of  the  heart,  from  which  the  great  vessels  are  given  off. 
The  latter  is  represented  by  a  line  across  the  sternum  at  the  level  of 
the  third  cartilages,  somewhat  higher  on  the  left  than  on  the  right, 
and  projecting  one  half  inch  to  the  right  and  nearly  one  inch  to  the 
left  of  the  sternum.  The  lower  border,  margo  acutus,  formed  by  the 
right  ventricle,  is  drawn  from  the  apex  to  the  junction  of  the  sixth  (or 
seventh)  right  costal  cartilage  with  the  sternum,  crossing  the  sternum 
near  the  costoxiphoid  junction.  This  line  is  nearly  horizontal  behind 
the  sternum,  slightly  convex  downward  to  the  left  of  it.  The  left  border, 
margo  obtusus,  formed  by  the  left  ventricle,  and  the  right  border,  formed 
by  the  right  auricle,  are  completed  by  lines  convex  laterally  which  con- 
nect the  left  and  right  ends  of  these  two  lines,  representing  the  base 
and  the  lower  border.  The  right  border  projects  one  to  two  fingers' 
breadths  from  the  right  sternal  margin  or  one  and  one  half  inches  from 
the  middle  of  the  sternum. 

The  auriculoventricular  groove  runs  from  the  third  left  to  the  sixth 
(or  seventh)  right  chondrosterual  junction.  The  pulmonary  orifice  is  the 
most  superficial.  It  lies  behind  the  sternal  end  of  the  left  third  costal 
cartilage,  but  the  sound  of  the  closure  of  the  valve  is  transmitted 
upward  with  the  blood  stream  and  is  heard  most  plainly  in  the  second 
left  space,  close  to  the  sternum.  The  aortic  orifice  is  a  little  below  and 
to  the  right  of  the  latter,  behind  the  left  half  of  the  sternum,  opposite 
the  third  space.  The  mitral  orifice  is  just  to  the  left  of  and  behind  the 
latter,  behind  the  left  border  of  the  sternum  and  opposite  the  third  space 
or  the  fourth  cartilage.  Notwithstanding  the  close  proximity  of  these 
two  most  important  valves  of  the  left  heart,  there  is  clinically  no  diffi- 
culty in  distinguishing  their  respective  sounds,  for  they  are  transmitted 
in  the  line  of  the  blood  stream,  so  that  the  sound  of  the  mitral  closure 
is  best  heard  near  the  apex  of  the  heart,  that  of  the  aortic  at  the 
sternal  end  of  the  second  right  intercostal  space.  The  points  of 
greatest  intensity  of  the  valvular  sounds  are  much  more  superficial 
than  the  valves  themselves,  especially  the  mitral  valve,  which  lies 
furthest  posteriorly,  behind  and  a  little  to  the  left  of  the  aortic  valve. 
The  tricuspid  valve  lies  behind  the  middle  of  the  sternum  about  the 
level  of  the  fourth  space. 

Displacements  of  the  Heart. — The  position  of  the  heart  varies 
slightly  with  its  systole  and  diastole  and  with  the  position  of  the  body. 


PLATE    XXVI 


FIG.  59. 


^SCAUENUS 

ANTICUS 


'3      ,//V*)^l  PULMONARX 


Relation  of  heart  and  great  vessels  to  the  anterior 
chest  wall.     (Joessel.^i 


WOUNDS  OF  THE  HEART.  227 

In  cJilldren  the  apex  is  higher,  in  t/te  aged  lower  than  the  position 
given  alcove,  the  differenee  between  the  two  amounting  to  a  full  inter- 
costal space.  The  heart  is  e/erafed  in  case  of  ascites,  tympanites  or 
tumors  of  the  abdomen  which  raise  the  diaphragm,  and  depressed  in 
case  of  effusion  into  the  pleural  cavity,  emphysema,  large  aoi-tic 
aneurism  and  mediastinal  tumors.  If  the  effusion  is  on  one  side  only, 
the  heart  is  disij/dccd  to  tJic  ojjjjo.sde  Hide.  Effusions  on  the  left  side 
especially  may  dis})lace  the  heart  to  such  an  extent  as  to  disturb  the 
circulation  and  to  displace  the  apex  to  or  beyond  the  right  margin  of 
the  sternum.  The  heart  may  also  be  pulled  to  either  side  by  a  con- 
tracting lung  or  pleural  adhesion.  The  dcHcent  of  the  heart  in  inspi- 
ration (about  one  inch)  is  not  as  great  as  it  is  made  to  appear  by  the 
elevation  of  the  ribs  in  front  of  it.  In  cases  of  tranapoaition  of  the 
vh'icera  the  apex  beat  is  found  on  the  right  side,  and  the  position  of 
the  heart  is  correspondingly  altered.  The  heart's  position  is  affected 
by  its  enla/'f/ement.  This  is  usually  at  first  in  the  nature  of  a  dilata- 
tion, and  then  the  walls  begin  to  thicken  or  hypertrophy  to  compensate 
for  the  dilatation.  Hence  an  aortic  obstruction,  that  may  for  instance 
be  the  cause  of  the  dilatation,  may  be  of  comparatively  little  im])(tr- 
tance  if  there  is  compensatory  hypertrophy  of  the  left  ventricle.  The 
ill  effects  on  the  heart  in  valvular  heart  disease  always  extend  in  the 
opposite  direction  to  that  of  the  blood  stream. 

The  heart  is  supplied  by  the  ric/ht  and  left  coronary  arteries,  the  first 
branches  of  the  aorta,  given  off  from  the  anterior  and  left  posterior 
sinuses  of  Valsalva  respectively.  They  run  in  the  auriculoventricular 
and  interventricular  grooves  and  are  exposed  to  injury  in  wounds  of 
the  heart.  Atheroma  of  these  arteries  causes  a  poor  blood  supply  of 
the  heart,  which  may  result  in  fatty  or  fibroid  degeneration  of  the  heart 
muscle,  or  in  angina  pectoris.  An  embolus  in  one  of  them  may  cause 
sudden  death  from  paralysis  of  the  heart  muscle. 

The  size  of  the  heart  is  roughly  speaking  that  of  the  closed  fist,  the 
weight  varies  greatly,  averaging  266  to  292  grams.  The  size  and 
weight  of  the  heart  increase  up  to  advanced  life  and  are  one  sixth  less 
in  the  female.  A  physiological  hypertrophy,  especially  of  the  left  ven- 
tricle, occurs  in  pregnancy. 

Wounds  of  the  heart  most  often  involve  the  anterior  surface,  and 
hence  concern  the  right  auricle  and  ventricle  and  the  left  coronary 
artery  and  its  accompanying  vein,  in  the  anterior  interventricular 
groove.  Wounds  in  the  third,  fourth  and  fifth  spaces  close  to  the 
right  of  the  sternum  are  liable  to  injure  the  rif/ht  auride,  those  in  the 
same  spaces  to  the  left  of  the  sternum  the  rif/lit  ventricle.  Wounds  of 
the  auricles  are  more  serious  and  more  raj)idly  fatal  than  those  of  the 
ventricles  owing  to  the  thicker  walls  of  the  latter  and  their  capacity  to 
contract  and  prevent  the  escape  of  blood.  For  a  similar  reason  wounds 
of  the  right  ventricle  are  more  serious  than  those  of  the  left.  Owing 
to  the  pf)sition  of  tiie  pleura  and  its  relation  to  the  pericardium,  a 
wound  of  the  normal  heart,  unless  it  penetrates  the  sternum  at  certain 
points,  must  also  pierce  the  pleura,  hence  blood  is  apt  to  be  found  in 


228  THE  THORAX. 

the  left  (more  rarely  in  the  right)  pleural  cavity.  Wounds  of  the  nor- 
mal heart,  except  over  the  area  of  cardiac  flatness,  involve  also  the 
anterior  margin  of  the  lung,  hence  air  may  escape  into  the  pericardial 
as  well  as  into  the  pleural  cavity.  Wounds  of  the  heart  are  not  as 
instantly  fatal  as  commonly  supposed.  If  death  occurs  at  once  it  is 
usually  due  to  interference  with  the  heart's  action  by  the  presence  of 
blood  which  has  escaped  into  the  pericardium,  and  not  to  the  effect  of 
the  injury  on  the  cardiac  nerve  centers.  Patients  with  apparently 
fatal  cardiac  injuries  have  lived  for  some  time  and  others  have  survived 
to  die  of  other  causes.  In  a  few  cases  the  foreign  body  causing  the 
injury  has  been  found  on  post-mortem  encapsulated  within  the  heart 
muscle.  Punctured  wounds  of  the  ventricle,  especially  of  the  left 
ventricle,  may  be  recovered  from.  Needles  have  not  infrequently  been 
found  imbedded  in  the  heart  muscle,  having  often  worked  their  Avay 
there  from  a  nearby  situation.  Operations  for  cardiac  injuries  appear 
to  afford  a  better  prognosis  than  if  no  operation  is  done.  The  superior 
vena  cava  may  be  wounded  by  a  stab  wound  in  the  first  or  second  right 
interspace  close  to  the  sternum. 

The  Aorta. 

The  first  or  ascending  portion  of  the  aorta  extends  upward,  forward 
and  to  the  right  in  the  axis  of  the  heart.  It  lies  behind  the  sternum 
and  passes  from  the  aortic  orifice,  behind  the  left  half  of  that  bone 
opposite  the  third  space,  to  the  upper  border  of  the  right  second 
chondrosternal  junction.  It  reaches  to  within  about  1  cm.  of  the 
root  of  the  innominate  artery  and  lies  irithin  the  pericardied  sac,  cov- 
ered by  the  sheath  of  the  serous  pericardium  common  to  it  and  the 
pulmonary  artery.  Hence  an  aneurism  of  this  part,  before  it  attains 
a  large  size,  very  commonly  bursts  into  the  pericardium,  causing  sud- 
den death. 

The  relations  of  the  aorta  are  of  importance  in  connection  with  the 
pressure  symptoms  of  aneurism  of  its  different  parts.  Aneurism,  so 
common  in  the  aorta  when  its  walls  are  affected  by  disease,  is  most 
likely  to  involve  the  ascending  part  for  this  is  not  strengthened,  like 
the  arch,  by  the  fibrous  layer  of  the  pericardium  blending  with  it. 
Moreover  it  is  the  first  part  to  receive  the  impulse  of  the  cardiac 
systole.  This  impulse  is  felt  especially  along  its  right  side  where  there 
is  a  normal  bulging  of  the  wall,  the  great  sinus  of  the  aorta,  from  which 
the  current  is  reflected  as  it  w^ere  toward  the  left  into  the  arch.  Aneu- 
rism of  the  ascending  portion  usually  bulges  to  the  right  and  forward. 
Hence  it  presses  on  the  superior  cava  on  the  right,  causing  congestion 
of  the  head,  upper  extremities  and  chest  wall,  and  on  the  sternum  in 
front  from  which  it  is  normally  separated  by  the  overlapping  right 
lung  and  the  remains  of  the  thymus  gland.  The  pulmting  tumor  first 
appears  in  the  second  right  sj^ace  but,  after  erosion  of  the  sternum, 
this  and  the  upper  right  cartilages  may  bulge  forward.  If  the  tumor 
is  directed  backward  it  may  press  upon  the  right  pulmonary  artery, 
which  lies  behind  it,  or  on  the  right  bronchus  behind  the  artery,  caus- 


THE  ARCH  OF  THE  AORTA.  229 

ing  a  deficient  blood  and  air  supply  to  the  right  lung  and  consequent 
dyspncea.  Again  the  aneurism  may  start  from  one  of  the  .s-innsr.s  of 
Va/.salv(i,  usually  the  right  or  anterior  one,  as  the  regurgitation  of 
blood  after  systole  occurs  particularly  here.  Such  a  tumor,  usually 
sacculated,  projects  chiefly  forward  and  to  the  right,  pressing  on  the 
pulmonary  artery  in  front  and  the  right  auricle  and  superior  vena  cava 
on  the  right.  The  f/reat  sinus  of  the  ascending  aorta  projects  a  slight 
and  varying  degree  to  the  right  of  the  sternum,  depending  partly  on 
the  breadth  of  the  sternum,  and  might  be  wounded  in  the  second  right 
Sj)aco. 

The  arch  of  the  aorta  is  badly  named  the  transverse  portion  of 
the  arch,  for  \iB  principal  direHion  is  backward,  from  about  one  fourth 
inch  behind  the  sternum,  at  the  second  right  chondrosternal  junction, 
to  the  left  side  of  the  body  of  the  fourth  thoracic  vertebra.  Its  fron.s- 
rcrse  course  corresponds  only  to  about  the  width  of  the  sternum.  The 
downwardly  directed  concavity  or  lou-er  border  corresponds  to  the 
junction  of  the  manubrium  and  body  of  the  sternum.  It  is  also  con- 
cave to  the  right  and  posteriorly.  Its  convexity  or  upper  border  cor- 
responds to  the  level  of  the  third  thoracic  spine,  the  middle  of  the  first 
costal  cartilages,  the  middle  of  the  manubrium  or  a  point  about  one 
inch  below  the  episternal  notch.  In  feeble  and  small-chested  persons 
it  may  reach  nearly  to  the  top  of  the  sternum  or  in  big-chested  men  it 
may  occasionally  lie  li  to  2^  inches  below  it.  It  is  covered  in  front  l)v 
the  margins  of  the  right  and  left  pleune  and  lungs  and,  between 
their  diverging  margins,  by  the  remains  of  the  thymus  gland.  Toward 
the  left  side  the  left  vagus  and  phrenic  nerves  cross  in  front  of  it  The 
left  reeiirrent  laryngad  nerve  arches  beneath  and  then  behind  it,  just  to 
the  left  of  the  remains  of  the  ductus  arteriosus,  which  connects  the 
arch  inferiorly  with  the  angle  of  bifurcation  of  the  pulmonary  artery, 
or  the  root  of  its  left  branch.  The  root  of  the  left  lung,  including  the 
left  bronchus,  pulmonary  artery,  etc.,  lies  below  it,  Behind-it  is  the 
lower  end  of  the  trachea,  just  above  or  at  its  bifurcation,  the  cesophagus, 
thoracic  duct,  and  the  left  recurrent  laryngeal  nerve.  Its  upper  border 
is  overlapped  by  the  left  innominate  vein,  Avhich  covers  the  roots  of  its 
three  branches  which  are  given  off  above,  from  its  convexity. 

A  consideration  of  these  relations  will  indicate  the  jjressure  si/nip}toin.'< 
of  an  aneurism,  which  depend  upon  its  position  and  the  direction  of 
its  extension.  The  most  common  situation  is  on  the  posterior  or  right 
((.sped,  where  it  may  press  upon  the  trachea,  causing  dyspnoea,  couj^h 
and  harsh  breathing,  and  on  the  left  recurrent  laryngeal  nerve  paralyz- 
ing the  left  vocal  cord,  altering  the  voice  and  so  simulating  laryngitis 
that  tracheotomy  has  sometimes  been  done.  Owing  to  its  pressing 
more  heavily  upon  the  trachea  in  the  reclining  position  the  patient  may 
be  unable  to  lie  down  with  comfort.  Extending  further  backward  it 
may  press  upon  the  (esophagus,  causing  dysphagia  and  simulating  (esopii- 
ageal  stricture,  or  upon  the  thoracic  duct,  causing  inanition.  Kvtcnsion 
foru-ard  would  involve  the  sternum  and  give  rise  to  a  pulsating  bulging 
tumor,  or  press  upon  the  left  vagus  or  phrenic  nerves.     In  case  otexfen- 


230  THE  THORAX. 

sion  downward  the  pressure  may  impede  the  circulation  through  the 
pulmonary  artery,  and  especially  its  left  branch,  causing  dyspnoea  or 
ev^en  cyanosis  from  the  scanty  oxidization  of  the  blood.  It  may  ob- 
struct the  left  bronchus,  causing  cough,  dyspnoea  and  left-sided  harsh 
and  diminished  breathing,  or  finally,  it  may  affect  the  left  recurrent 
laryngeal  nerve.  Upward  extension  of  the  tumor  causes  pressure  on 
the  left  innominate  vein,  resulting  in  serious  congestion  of  the  left  side 
of  the  head  and  neck  and  the  left  upper  extremity,  or  upon  one  or 
more  of  the  primary  branches  of  the  aorta,  compressing  or  even  oblit- 
erating them,  and  causing  inequality  of  the  carotid  or  radial  pulses  on 
the  two  sides. 

The  tumor  may  extend  up  into  the  root  of  the  neck,  resembling 
aneurism  of  the  innominate,  left  carotid  or  subclavian  arteries,  and 
cause  difficulty  in  diagnosis.  Aneurisms  of  the  ascending  aorta  and 
the  arch  of  the  aorta  are  liable  to  lower  the  heart  and  to  disturb  the 
heart's  action  by  pressure  upon  the  cardiac  plexuses.  They  may  burst 
into  any  of  the  cavities  or  hollow  tubes  with  w'hich  they  are  in  con- 
tact, causing  a  sudden  fatal  hemorrhage.  The  percussion  note  may  be 
dull  over  a  considerable  area,  owing  to  displacement  of  the  lungs 
laterally. 

Most  descriptive  text-books  speak  of  a  short  third  or  descending 
portion  of  the  arch,  but  there  is  no  sufficient  reason  for  separating  this 
from  the  descending  thoracic  aorta,  which  extends  from  the  fourth 
thoracic  vertebra  to  the  aortic  orifice  of  the  diaphragm,  opposite  the 
twelfth  vertebra  and  slightly  to  the  left  of  the  median  line  (Joessel). 
Superiorly  it  lies  to  the  left,  inferiorly  in  front  of  the  thoracic  spine, 
superiorly  to  the  left  and  inferiorly  behind  and  to  the  right  of  the 
oesophagus,  and  superiorly  to  the  left  and  at  its  lower  level  in  front  of 
the  thoracic  duct.  Furthermore  it  passes  behind  the  root  of  the  left 
lung,  grooves  this  lung  near  its  posterior  border,  and  lies  behind  the 
pericardium  and  to  the  left  of  the  vena  azygos  major.  Aneurism  of 
this  part  may  press  npjon  and  obstruct  any  of  the  above-mentioned 
parts,  erode  the  spine  and  the  vertebral  ends  of  the  left  middle  ribs, 
cause  pressure  upon  and  neuralgia  of  the  corresponding  left  thoracic 
nerves,  and  bulge  posteriorly  to  the  left  of  the  spine  as  a  pulsating 
tumor,  sometimes  of  enormous  size.  It  may  eventually  burst  on  the 
surface  or  into  the  oesophagus,  left  bronchus,  pericardium,  pleura  or 
posterior  mediastinum. 

Variations. — The  arch  of  the  aorta  is  liable  to  occasional  variations 
in  its  position  and  direction,  with  or  without  transposition  of  the  vis- 
cera, and  to  frequent  variations  in  the  number  and  arrangement  of  its 
primary  branches.  These  variations  may  decrease  the  number  of  pri- 
mary branches  to  two  or  increase  them  to  four,  five  or  six.'  These 
anomalies  are  to  be  explained  by  abnormalities  in  the  embryonic  derelop- 
ment  of  these  parts  from  the  ventral  and  dorsal  stems  and  the  bran- 
chial arches.     The  only  variation  of  much  surgical   interest  is    the 

^  For  the  above  variations  see  Henle's  Anatomy  (1868),  Vol.  HI.,  pp.  203  ot  seq. ; 
Morris'  Anatomy,  2d  ed.,  pp.  471,  472,  etc. 


THE  SPLANCHNIC  NERVES.  231 

origin  of  the  carotid,  usually  the  left,  from  the  innominate  stem  of  the 
opposite  side,  in  which  case  it  may  cross  the  trachea  so  as  to  be  in 
danger  of  injnry  in  traciieotomy.  Xot  infrequently  the  ritjht  aahelarian 
arises  from  the  left  end  of  the  arch  and  passes  behind  the  trachea  and 
oesophagus  to  reach  its  normal  position. 

The  innominate  and  left  common  carotid,  given  off  immediately  be- 
hind the  middle  of  the  manubrium,  mount  thence  to  the  right  and  left 
sternoclavicular  joints,  tiie  former  artery  dividing  opposite  the  upper 
border  of  the  right  joint.  The  innominate  artery  (1^  to  2  in.  long) 
has  the  left  innominate  and  right  inferior  thyroid  veins  in  front ;  the 
right  innominate  vein,  pneumogastric  nerve,  pleura  and  lung  to  the 
right ;  the  trachea  behind  and  to  the  left,  and  the  left  carotid  artery 
to  the  left.  These  relation-s,  and  the  occasional  origin  from  it  of  the 
thyroidea  ima  artery,  are  of  importance  in  the  diagnosis  of  aneui-ism  of 
this  artery  from  the  pressure  symptoms,  and  in  its  ligation  for  aneu- 
rism of  its  branches,  successful  reported  cases  of  which  are  on  the  in- 
crease. The  dangers  of  the  operation  itself  lie  in  the  imj)ortant  struc- 
tures in  relation  with  it  and  in  the  difficulty  of  an  adequate  exposure, 
which  may  be  facilitated  by  osteoplastic  resection  of  the  manubrium 
(Bardenheuer),  or  better  by  a  longitudinal  median  section  of  the 
sternum,  or  its  upper  half,  and  the  lateral  retraction  of  the  divided 
edges,  whicii  exposes  the  mediastinum  and  its  contents. 

The  pulmonary  artery,  in  its  course  from  the  third  left  to  the  upper 
border  of  the  second  left  chondrosternal  junction,  projects  more  or  less 
beyond  the  left  border  of  the  sternum  in  the  second  space,  where  it  is 
exposed  to  injury.  Similarly  on  the  right  side  the  superior  vena  cava, 
from  its  origin  behind  the  sternal  end  of  the  first  costal  cartilage  to  its 
termination  behind  that  of  the  third  cartilage,  lies  just  to  the  right 
of  the  sternum  and  ascending  aorta,  and  is  exposed  to  injury  in  the 
mesial  ends  of  the  first  and  second  spaces.  The  left  innominate  vein 
crosses  transversely  behind  the  manubrium,  just  above  the  aortic  arch 
and  just  below  the  episternal  notch,  and  in  children  and  cases  of  high 
position  of  the  aortic  arch  it  may  project  above  the  bone  so  as  to  be 
exposed  to  injury  in  a  low  tracheotomy  or  in  some  thyroidectomies. 
The  azygos  veins  are  of  practical  importance  on  account  of  the  free 
collateral  circulation  they  afford  between  the  inferior  and  superior  cava?, 
in  case  of  obstruction  of  the  former.  This  is  due  to  their  connection 
with  the  liuubar,  ilio-lumbar,  common  iliac  and  renal  veins. 

The  great,  small  and  least  splanchnic  nerves,  derived  from  the  fifth 
to  ninth,  the  tenth  to  eleventh,  and  the  twelftli  thoracic  sympathetic 
ganglia  respectively,  are  connected  with  the  lower  thoracic  nerves, 
which  supply  the  abdominal  ])arietes.  As  they  pass  to  the  solar  and 
renal  plexuses,  which  supply  the  abdominal  viscera,  they  account  for 
the  rejlcxes  between  the  abdominal  viscera  and  parietes  (see  p.  251), 
and  for  the  pain  in  some  diseases  of  the  liver  and  stomach,  in  the 
region  between  and  over  the  scapula^  supplied  by  the  dorsal  branches 
of  the  thoracic  nerves,  which  are  connected  with  the  splauchnics. 
Pressure  of  thoracic  tumors  or  ancuri,^ms  upon  the  sympathetic  may  cause 


232  THE  THORAX. 

dilatation  of  the  pupil  of  that  side,  from  irritation  of  the  nerve,  or  con- 
traction of  the  pupil,  from  paralysis  of  the  nerve.  As  some  filaments 
of  the  right  phrenic  nerve  pass  to  the  solar  plexus  and  liver,  the  pain 
over  the  tip  of  the  shoulder  in  liver  disease  may  be  explained  as  a 
reflex  in  the  acromial  filaments  from  the  third,  fourth  and  fifth  cervical 
nerves  from  which  the  phrenic  is  derived. 

The  Thoracic  Duct. 

This  is  about  eighteen  inches  lone/  from  its  commencement  in  the 
abdomen  in  the  recepfacii/u)a  cJu//i,  opposite  the  second  (or  first)  lumbar 
vertebra,  to  its  termination  in  the  neck  in  the  posterior  part  of  the 
angle  of  union  of  the  subclavian  and  internal  jugular  veins,  and  is 
mostly  contained  within  the  thorax.  Here,  after  passing  through  the 
aortic  opening  of  the  diaphragm  behind  the  aorta,  it  lies  between  the 
latter  and  the  vena  azygos  major  in  the  posterior  mediastinum  up  to  the 
level  of  the  fifth  thoracic  vertebra  where  it  inclines  to  the  left  behind 
the  oesophagus,  the  aortic  arch  and  the  left  common  carotid  artery. 
Thence  in  the  superior  mediastinum  it  lies  between  the  oesophagus  and 
the  left  pleura,  behind  the  left  subclavian  artery  and  in  front  of  the 
vertebral  artery.  After  ascending  through  the  superior  thoracic  aper- 
ture into  the  lefi  side  of  the  neck  as  high  as  the  seventh  cervical  verte- 
bra, it  arches  outward,  forward  and  downward  over  the  apex  of  the 
pleura,  in  front  of  the  subclavian  artery,  the  scalenus  anticus  muscle 
and  the  vertebral  vein  and  behind  the  left  internal  jugular  vein  and 
the  carotid  artery,  becoming  external  to  the  latter.     (Fig.  60.) 

The  hif/hest  point  of  the  arch  of  the  thoracic  duct  normally  reaches  the 
level  of  the  transverse  process  of  the  sixth  cervical  vertebra.  Although 
in  the  thoracic  cavity  it  may  be  pressed  upon  by  tumors  and  aneurisms 
and  its  rupture  is  reported  by  Krabbel  in  a  case  of  fracture  of  the 
ninth  thoracic  vertebra,  followed  by  a  chylous  effusion  of  more  than  a 
gallon  in  the  right  pleural  cavity,  it  is  in  the  neck  that  its  surgical  in- 
terest lies.  Here  it  has  been  u-ounded  by  stab  and  bullet  wounds  and 
in  extensive  operations  for  tumors  or  tubercular  glands  of  the  neck. 
The  near  neighborhood  of  many  vital  parts  would  render  rapidly  fatal 
most  injuries  of  the  duct,  unless  received  during  a  surgical  operation. 
Under  normal  anatomical  conditions  operative  injury  is  very  unlikely 
as  the  duct  does  not  rise  above  the  level  of  junction  of  the  two  great 
veins,  but  it  not  infrequently  rises  higher  and  has  been  found  as  high 
as  5|  cm.  above  tlie  sternum  (Dietrich).  When  injured  it  has  been 
successfully  sutured  in  a  few  cases  and  its  leakage  has  been  checked  by 
clamps  or  packing. 

Its  obliteration  has  occurred  without  producing  any  marked  symp- 
toms, though  experimental  ligation  in  dogs  has  been  followed  by 
rupture  of  the  receptaculum  chyli  or  other  fatal  lesions.  A  double 
perfect  valve  at  its  entrance  into  tlie  vein  guards  against  regurgitation 
of  lymph  or  the  entrance  of  blood.  It  may  enter  the  veins  as  a  delta. 
It  receives  the  lymph  and  chyle  from  all  parts  of  the  body  except  the 
right  upper  extremity,  the  right  side  of  the  chest,  head  and  neck  and 


PLATE   XXVI  I 


FIG.  60. 


THORACIC_ 
DUCT 


VERTEBRAL 
VEIN 


BRACHIAL 
PLEXUS 


SUPERFIC.   CER 

VICAL    VEIN 
SUBCLAV.   LYMPH 
^^       TRUNK 
SUBCLAV.   AF.TERV 


// 


Topography  of  the  thoracic  duct  in  the  neck. 
(Zuckerkandl.) 


THE  LUMEN  OF  THE  (ESOPHAGUS.  233 

the  convex  surface  of  the  liver,  which  is  returned  by  the  right  lymphatic 
duct  to  a  corresponding  point  of  the  veins  on  the  right  side.  Its  injury 
is  of  less  moment. 

The  CEsophagus. 

Like  the  thoracic  duct  the  (t'.so{)liagiis  is  contained  partly  in  the  neck 
and  abdomen  but  mostly  in  the  thoracic  cavity,  in  the  superior  and 
posterior  mediastina.  Ti)e  lei-ei  of  flie  roiiimeuceiiiciit  of  the  fx'sophagus, 
as  the  continuation  of  the  pharynx,  depends,  like  that  of  the  trachea, 
on  the  position  of  the  head  and  neck  and  varies  from  the  fifth  to  the 
sixth  or  seventh  cervical  vertebrae.  In  a  position  midway  between 
flexion  and  extension  of  the  neck  its  upper  end,  beliind  the  lower 
border  of  the  cricoid  cartilage,  is  opposite  the  sixth  cerrico/  i-ertehra. 
Its  lower  eiul  passes  through  the  diaphragm,  opposite  the  tenth  thoracic 
vertebra,  to  end  in  the  stomach,  opposite  the  eleventh  vertebra.  Its 
length  (23  to  2G  cm.)  averages  9 J  to  10  inches,  which  with  the  dis- 
tance of  its  upper  end  from  the  upper  incisor  teeth,  6  in.,  makes  the 
average  distance  from  the  latter  to  the  stomach  \b\  to  16  in.  (17  cm, 
in  the  new-born  (Mouton).  The  length  of  the  cervical  portion,  i.  r., 
above  the  episternal  notch  or  the  second  thoracic  intervertebral  disc, 
averages  5  to  7  cm.  and  ranges  between  4|  and  Si  cm.  (Tillaux),  vary- 
ing w^ith  the  length  and  position  of  the  neck. 

Its  direction  (Fig.  58)  is  not  straight.  It  inclines  to  the  left  in  the 
neck  but  is  pressed  back  to  the  median  line  by  the  left  end  of  the 
aortic  arch,  opposite  the  fourth  thoracic  vertebra.  Below  this  it  again 
curves  slightly  to  the  left,  so  that  its  diaphragmatic  orifice  is  normally 
somewhat  to  the  left  of  the  median  line  and  to  the  left  and  in  front  of 
the  aorta.  In  the  sagittal  plane  it  follows  the  curved  line  of  the 
vertebrfe  to  the  fourth  thoracic  vertebra,  below  which  it  gradually 
leav^es  the  vertebrae  and  passes  more  vertically  to  its  diaphragmatic 
orifice.  None  of  its  curves  are  of  sufficient  extent  or  degree  to  inter- 
fere with  the  passage  of  bougies  or  instruments. 

The  lumen  of  the  oesophagus,  except  during  the  act  of  swallowing 
or  vomiting,  is  always  closed  in  the  cervical  portion,  sometimes  closed 
and  sometimes  open  in  the  thoracic  portion,  according  as  the  stomach 
is  full  or  empty  of  gas  or  fluid.  The  caliber  of  the  oesophagus,  which 
is  the  narrowest  section  of  the  alimentary  canal,  varies  and  presents 
three  constricted  parts,  one  at  its  commencement,  another  7  cm.  below, 
and  the  third  at  its  passage  through  the  diaphragm,  22  cm.  below. 
The  latter  is  not  a  narrowing  of  the  tube  itself  but  is  due  to  the  fibers 
of  the  diaphragm  which  surround  it  and  form  a  kind  of  canal  for  it. 
The  loivest  constriction  is  the  narroircst,  measuring  12  ram.  in  (liamcfer 
as  compared  to  14  mm.  for  the  upper  two,  but  it  is  )norc  distensible, 
allowing  of  rapid  dilatation  to  22  mm.,  the  other  two  to  18  or  19  mm. 

It  follows  that  in  a  normal  oesophagus  a  bougie  14  mm.  in  diameter 
should  pass  easily,  otherwise  there  is  a  stenosis,  and  that  in  dilatinc/ 
the  cesophagus  an  instrument  of  IS  mm.  diameter  should  be  the  limit. 
In  the  neir-l)orn  the  caliber  of  the  oesophagus  is  4  mm.  On  account 
of  a  spasmodic  muscular  contraction  the  introduction  of  a  bougie  may  be 


231  THE  THORAX. 

hindered  at  the  upper  end  of  the  oesophagus  and  lower  down  it  may  be 
suddenly  held  in  the  same  way.  During  the  muscular  spasm  the 
sound  should  be  left  at  rest,  as  the  attempt  to  force  it  increases  the 
spasm.  Owing  to  the  firm  relations  in  front  of  and  behind  the 
oesophagus,  /.  e.,  trachea  and  vertebrae,  it  is  less  distensible  in  these 
directions  than  laterally,  as  seen  in  sword  swallowing.  Accordingly 
some  olive-tipped  bougies  are  made  flattened. 

Any  foreign  body  which  w^ill  pass  the  upper  two  narrow  points  will 
probably  pass  the  lower  one.  Foreign  bodies  are  therefore  most  likely 
to  be  arrested  at  the  upper  end  of  the  oesophagus,  or  the  lower  end  of 
the  pharynx,  where  the  predominance  of  striped  muscle  tissue  in  the 
walls  often  allows  of  their  being  returned  to  the  mouth  by  a  spasmodic 
muscular  action.  If  this  fails  they  may  be  removed  by  some  form  of 
oesophagus  forceps,  as  may  also  those  bodies  arrested  at  the  second 
narrow  point,  which  begins  3i  cm.  and  is  narrowest  7  cm.  below.  If 
the  forceps  fails  to  remove  a  body  arrested  at  the  second  constriction 
the  alternatives  present  of  pushing  it  down  to  the  stomach  or  remov- 
ing it  by  an  external  oesophagotomy. 

Strictures  of  the  oesophagus,  both  malignant  and  cicatricial,  are 
most  likely  to  be  found  at  one  of  the  constricted  points.  The  cica- 
tricial variety  occurs  most  frequently  at  the  narrow  points  because 
the  corrosive  fluid  swallowed  takes  slightly  longer  in  passing  these 
points  and  hence  acts  more  intensively  on  the  oesophageal  wall,  caus- 
ing deeper  ulceration  and  greater  subsequent  contraction.  Cancerous 
stricture  is  most  common  at  the  upper  or  lower  ends,  and  in  the  latter 
case  the  symptoms  are  not  infrequently  referred  to  the  upper  end. 

The  lymphatics  enter  the  mediastinal  and  cervical  lymphatic  nodes 
so  that  if  cancer  of  the  oesophagus  is  suspected  we  should  examine  the 
nodes  at  the  root  of  the  neck. 

The  relations  of  the  oesophagus  are  especially  important  at  the  nar- 
roir  points  where  lesions  are  likely  to  occur  and  in  the  neck  where 
oesophagotomy  is  done  and  where  other  operations  and  injuries  may 
concern  it.  The  second  constriction  is  about  behind  the  aortic  arch 
and  foreign  bodies  arrested  here  have  idcerated.  through  into  the  aorta, 
causing  immediate  and  fatal  hemorrhage.  Thus  a  five-franc  coin 
(Mus6e  Dupuytren),  a  fish  bone  (Lancet,  1871),  etc.,  have  been 
re|)orted  ulcerating  into  the  aorta,  and  a  piece  of  bone  impacted  in  the 
oesophagus  has  been  reported  (Ogle,  in  Path.  Soc.  Trans.,  Vol.  IV.) 
ulcerating  into  an  intervertebral  disc  and  setting  up  a  fatal  disease  of 
the  cord.  Aneurism  of  the  aortic  arch  or  descending  aorta  may  press 
upon  the  oesophagus  and  simulate  stricture  of  its  lumen.  A  bougie 
passed  under  such  conditions  may  penetrate  the  sac  and  bring  on  a 
sudden  fatal  bleeding.  Similarly  an  impacted  body  or  an  epithelioma 
has  ulcerated  into  the  lower  end  of  the  trachea,  the  left  bronchus  or 
the  right  pulmonary  artery,  which  also  lies  in  front  of  the  oesophagus. 
An  instrument  passed  in  case  of  a  carcinomatous  stricture  of  the 
oesophagus  may  readily  pierce  the  softened  wall  of  the  tube  and 
penetrate    the    trachea    or    left  bronchus,  setting  up   a  septic    pneu- 


PLATE  xxvn  r. 


FIG.    61. 


STERNUM  RIGHT    AURICLC 

V.    CAVA   SUP. 


RT.     PHHENI 


L      AURICLC 


SERRAT.     MAJ. 


Transverse  horizontal  section  of  tlie  body  at  the  level 
of  the  8th  thoracic  vertebra.     (Joessel.) 


THE  RELATIONS  OF  THE  (ESOPHAGUS.  235 

monia,  or  it  may  wound  the  aorta,  pericardium,  pleura,  etc.,  with 
a  fatal  result.  The  contiguity  of  the  esophagus  with  the  membraneous 
wall  of  the  trachea  and  with  the  left  l)ronchus  explains  the  effect  of 
foreign  bodies  in  the  one  producing  symptoms  of  obstruction  referable 
to  the  other,  so  that  tracheotomy  has  been  done  for  a  foreign  body  in 
the  oesophagus.  Of  course  foreign  bodies,  especially  sharp  or  irreg- 
ular ones,  may  become  arrested  elsewhere  than  at  the  narrowest  points. 

The  (lorta  winds  spirally  around  the  oesophagus,  being  in  front  above, 
then  to  the  left,  then  behind  and  finally  behind  and  to  the  right.  lUion: 
the  aortic  arch  the  oesophagus  is  just  behind  the  bronchial  glands  and 
the  pericardium  and  corresponds  to  the  left  auricle,  so  that  in  enlarge- 
ment of  the  heart  or  distension  of  the  pericardium  with  fluid  the  patient 
may  be  unable  to  swallow  with  comfort  in  the  supine  position.  The 
oesophagus  lies  between  the  two  pleural  sacs  but  in  more  direct  contact 
with  the  left  above  and  the  right  below.  Hence  carcinoma  of  the 
oesophagus  is  said  to  extend  to  the  right  lung  and  pleura  more  often 
than  to  the  left,  though  I  have  observed  it  on  the  left  side.  The  fhomcic 
duct  is  to  the  right  below,  to  the  left  above  and  crosses  behind  it  about 
the  fourth  or  fifth  thoracic  vertebra.  Loose  cellular  tissue,  continuous 
with  that  behind  the  pharynx,  connects  the  oesophagus  with  the  vertebrae 
and  along  this  a  retropharyngeal  abscess  or  a  deep  abscess  of  the  neck 
may  descend  into  the  mediastinum  and  press  upon  the  oesophagus. 

In  the  neck  its  relations  are  of  importance  especially  on  ilic  left  side, 
on  which  external  oesophagotomy  is  performed  as  the  oesophagus  inclines 
to  the  left.  In  this  operation  the  left  recurrent  laryngeal  nerve,  the 
inferior  thyroid  artery  and  the  left  lobe  of  the  thyroid  gland,  which 
lie  in  front  of  the  left  side  of  the  oesophagus,  must  be  carefully 
avoided.  After  incising  along  the  anterior  border  of  the  sternomastoid, 
from  the  thyroid  cartilage  downward,  this  muscle  and  the  carotid 
sheath  are  retracted  outward,  the  other  structures  inward.  On  the 
ri(/Jd  .side  the  carotid  sheath  is  further  removed  from  the  a\sophagus 
and  the  recurrent  laryngeal  nerve  runs  more  along  its  lateral  border. 
The  modern  operation  of  gastrostomy  gives  good  results  and  is  far 
preferable  to  oesophagostomy.  In  cicatricial  strictures  there  is  a  pouch- 
like  dilatation  of  the  oesophagus  above  the  stricture,  the  opening  of 
which  is  usually  excentric  so  as  to  prevent  the  passage  of  bougies. 
Hence  the  retrograde  dilatation  through  an  opening  in  the  stomach  is 
the  best  method.'  Foreign  bodies  impacted  at  the  lower  end  may  be 
removed  by  gastrotomy  (Richardson). 

Cone/enitally  the  oesophagus  may  be  deficient  in  part  and  ojien  into 
the  trachea  below  or,  more  rarely,  above.  There  may  also  be  a 
tracheo-oesophageal  fistula,  an  annular  stricture,  a  dilatation  or  a 
doubling  or  division  of  the  tube.  True  dircrficida,  both  jnilsion 
and  traction  diverticula,  are  acquired,  the  former  due  to  a  hernia  of 
the  mucosa  through  the  inferior  constrictor  of  the  pharynx  at  the 
upper  end  of  the  oesophagus  or  the  lower  end  of  the  pharynx,  the 
latter  due  to  the  contraction  of  scar  tissue  connecting  the  cesophagus 
with  surrounding  parts  (/.  e.,  bronchial  glands,  etc.). 

'See  article  by  tlie  writer  in  Annals  of  Surgery,  March,  1S95. 


CHAPTER   IV. 

THE   ABDOMEN. 

Shape. — In  general  the  abdomen  is  barrel-shaped,  flattened  from 
before  backwards,  and  wider  below  than  above.  In  the  adn\t  female 
the  larger  circnmference  below  than  above  is  dne  to  the  size  of  the 
pelvis  and  is  still  more  marked  when  the  upper  part  has  been  com- 
pressed by  corsets.  In  childhood,  owing  to  the  incomplete  develop- 
ment of  the  pelvis,  the  abdomen  is  larger  above  than  below,  especially 
in  its  transverse  diameter.  The  height  of  the  abdomen  in  the  female  is 
greater  than  in  the  male  owing  to  the  greater  size  of  the  lumbar  ver- 
tebrae. The  long  axis  of  the  abdominal  cavity  is  not  vertical  but  ob- 
lique from  above  downwards  and  to  the  right,  owing  to  the  greater 
height  of  the  diaphragm  on  the  right  side.  The  infraahdovunal  pres- 
sure acting  most  strongly  in  this  line  is  said  to  account  for  the  greater 
frequency  of  hernia  on  the  right  than  on  the  left  side. 

In  fed  subjects  the  abdomen  protrudes  to  a  varying  degree  in  front, 
owing  to  the  deposit  of  fat  among  the  abdominal  viscera  and  the  peri- 
toneal folds  and  to  the  large  amount  of  subcutaneous  adipose  tissue. 

In  infants  the  abdomen  protrudes  in  front,  owing  to  the  relatively 
large  size  of  the  liver  and  the  small  size  of  the  pelvis,  which  crowds 
the  pelvic  viscera  (bladder,  rectum,  etc.),  partly  up  into  the  abdomen. 
The  latter  condition,  apart  from  the  amount  of  fat,  accounts  for  the 
protrusion  of  the  abdomen  in  children  until  the  pelvis  enlarges  at  the 
approach  of  puberty. 

Certain  physiological  and  pathological  conditions  cause  a  general  or 
local  protrusion  of  the  abdomen,  such  as  pregnancy,  ascites,  and  tumors 
of  the  abdominal  contents  or  walls.  After  such  long-continued  dis- 
tension, an  undue  amount  of  prominence  or  pendulousness  often  re- 
mains. 

In  cases  of  great  emaciation  from  starvation  or  wasting  disease,  the 
contour  of  the  abdomen  is  much  depressed  in  front  and  especially  just 
beneath  the  costal  margin  where  the  slight  normal  median  depression, 
known  as  the  ^'  pit  of  the  stomach^'  (or  scrobiculus  cordis)  may  become 
so  marked  that,  in  the  recumbent  position,  the  wall  sinks  away  almost 
vertically  from  the  costal  margin  and  the  prominence  of  the  vertebrae 
is  noticeable.  In  tubercular  meningitis  the  abdomen  shows  a  "  boat- 
shaped  "  depression  in  front,  owing  to  the  contraction  of  the  empty 
bowels. 

Boundaries. — The  abdomen,  including  the  pelvis,  is  bounded  above 
by  the  diaphragm,  which  separates  it  from  the  thorax,  belon^  by  the 
pelvic  floor.     A  plane  drawn  through  the  base  of  the  ensiform  carti- 

236 


LANDMARKS.  237 

lage  in  front  and  tlie  tenth  thoracic  spine  behind  suggests  the  upper 
limit  of  tlie  cavity,  which,  however,  ascends  even  higher  than  tliis  into 
the  vault  of  the  diaphragm. 

The  actual  upper  limit  of  the  abdomen,  extending  up  as  it  does 
under  cover  of  the  lower  ribs  and  costal  cartilages,  is  higher  than  the 
api)arent  limit,  /'.  r.,  the  costal  margin. 

It  is  hounded  fjrhind  by  the  lumbar  vertebrte,  sacrum,  lower  two  or 
three  ribs,  diaphragm,  lumbar  muscles  and  the  posterior  portions  o 
the  ilia ;  in  front,  by  the  free  ends  of  the  false  ribs  and  costal  carti- 
lages, the  symphysis,  the  body  and  rami  of  the  pubis,  and  the  ventral 
abdominal  muscles  ;  laterol/ij,  by  the  lower  ribs  and  diaphragm,  the 
ilia  and  ischia,  and  the  fleshy  portions  of  the  flat  abdominal  muscles. 

Except  for  operations  on  subdiaphragmatic  and  liver  abscesses,  after 
suture  of  the  diaphragm  to  the  opening  in  the  costal  pleura,  no  opera- 
tions arc  done  through  the  upper  boundary  or  diaphragm.  Many 
operations  are  performed  through  the  perineum  and  the  pelvic  floor  on 
the  rectum,  female  pelvic  organs,  and  male  genito-urinary  organs. 
Hahn's  operation  for  gastrostomy  is  done  through  the  eighth  intercostal 
space,  and  occasionally  the  iliac  fossa  has  been  perforate<l  for  drainage 
of  an  abscess.  Otherwise  abdominal  operations  are  performed  through 
the  soft  parts  which  indicate  the  apparent  limit  of  the  abdomen  and 
form  an  hexagonal  area  bounded  by  the  costal  cartilages  of  the  six 
lower  ribs  and  by  the  twelfth  ribs  above,  the  transverse  processes  of 
the  lumbar  vertebrae  behind,  and  by  the  iliac  and  pubic  crests  and 
Poupart's  ligament  below. 

Superficial  Markings  and  Landmarks. 

Bony  Points. — Superiorly  the  eiisijorm  carti/o.ge  and  the  diverging 
margins  of  the  costal  cartilaf/es  are  often  visible  and  always  j)alpable. 
The  tip  of  the  ensiform  cartilage  is  about  on  a  line  with  the  lower  part 
of  the  tenth  thoracic  vertebra.  There  is  a  palpable  notch  on  t/ic  costal 
margin  between  the  tip  of  the  tenth  and  the  border  of  the  ninth  costal 
cartilage,  which  is  a  useful  landmark. 

The  tips  of  the  eleventh  and  tireljth  costal  cartilages  lie  free  between 
the  abdominal  muscles.  They  can  be  readily  felt  except  in  fat  sub- 
jects, but  it  is  never  safe  to  rely  upon  palpation  alone  in  determining 
the  twelfth  rib  (see  p.  282)  and  the  ribs  should  always  be  counted 
from  above  to  locate  the  twelfth  rib  in  lumbar  operations. 

As  the  spine.s  of  the  hunhar  rertehnr  closely  correspond  with  the 
level  of  their  bodies,  some  of  the  relations  of  the  latter  may  here  be 
given,  according  to  Holden  and  Windle  : 

First  luml)ar  vertebra  and  spine  :  pancreas,  pelvis  of  kidncv  with 
endings  of  renal  arteries.  Junction  of  first  and  second  :  end  uf  sjiinal 
cord.  Third  :  lower  border  of  kidney.  Junction  of  third  and  fourth  : 
umbilicus.  Fourth  :  highest  part  of  iliac  crest,  bifurcation  of  aorta. 
Third  sacral  vertebra  :  limit  of  sjiinal  membranes. 

The  anterior  superior  iliac  spine  is  an  important  landmark  in  de- 
termining the  length  of   the    lower  extremities    in   fractures  of  the 


238  THE  ABDOMEN. 

femur  and  in  injuries  and  diseases  about  the  hip  joint.  On  a  line 
between  it  and  the  umbilicus,  at  the  outer  border  of  the  rectus  is 
"  McBurney^s  point,"  commonly  the  point  of  greatest  tenderness  in 
appendicitis.  This  spine  is  at  the  outer  extremity  of  the  inguinal  fold 
(due  to  Poupart's  ligament)  where  in  thin  subjects  it  is  visible  as  a 
prominence,  in  fat  subjects  as  a  depression,  and  in  all  subjects  it  is 
palpable.  It  lies  in  a  plane  about  on  a  level  with  the  top  of  the  pro- 
montory of  the  sacrum,  in  the  erect  position. 

Extending  outward  and  upward  from  this  spine  the  sinuous  ili((c 
crest  may  be  felt  throughout,  except  dorsally  in  very  fat  subjects.  In 
muscular  subjects  it  lies  in  a  groove  {iliac  furrow)  below  the  fleshy 
fibers  of  the  external  oblique  muscle.  It  ends  dorsally  in  the  posterior 
superior  iliac  spine,  often  difficult  to  feel,  but  indicated  by  a  slight 
depression  on  a  level  with  the  spinous  process  of  the  second  sacral 
vertebra. 

The  pubic  spine  is  another  bony  landmark  of  special  importance 
in  the  anatomy  of  hernia,  lying  external  to  the  neck  of  an  inguinal 
hernia,  internal  to  that  of  a  femoral.  It  lies  at  the  inner  end  of  the 
inguinal  furrow  and  Poupart's  ligament.  It  is  readily  palpable  ex- 
cept in  fat  subjects  in  whom  it  may  be  found  by  following  up  the  ad- 
ductor longus  tendon,  and  in  the  male,  by  invaginating  the  scrotum 
and  thus  getting  beneath  the  subcutaneous  fat.  It  lies  in  the  same 
horizontal  plane  with  the  upper  border  of  the  great  trochanter.  Be- 
tween it  and  the  symphysis  pubis  the  pubic  crest  may  be  felt,  except 
in  the  obese. 

Lines,  Muscles,  etc. — The  linea  alba  (see  also  p.  245)  corresponding 
to  the  fibrous  interval  between  the  two  recti  muscles,  is  marked  by  a 
slight  median  groove  (the  abdominal  furrow)  from  the  infrastern(d 
depression  (pit  of  the  stomach),  below  the  ensiform  cartilage,  to  just 
below  the  umbilicus.  Below  this  it  is  not  visible  owing  to  the  close 
approximation  of  the  recti  muscles,  the  lower  ends  of  which  are  con- 
cealed by  a  small  amount  of  fat. 

The  umbilicus  (see  also  p.  257)  lies  three  fourths  to  one  inch  above 
the  bifurcation  of  the  aorta,  on  a  line  connecting  the  highest  points  of 
the  iliac  crests  and  on  a  level  with  the  disc  between  the  third  and 
fourth  liniibar  vertebrae,  and  the  lower  end  of  the  third  lumbar  spine. 
Whereas  at  birth  it  lies  below  the  center  of  the  body,  in  the  adult  it 
is  above  this  point,  which  lies  nearer  the  symphysis  pubis.  It  always 
lies  below  the  center  of  the  linea  alba,  about  the  junction  of  its  upper 
three  fifths  with  the  lower  two  fifths,  though  it  varies  in  position  with 
the  obesity  of  the  subject. 

The  linea  semilunaris  (see  also  p.  244)  corresponds  to  the  outer 
border  of  each  rectus  muscle  and  may  be  well  seen,  when  that  muscle 
is  in  action,  as  a  slightly  curved  line  convex  laterally,  from  the  tip  of 
the  ninth  costal  cartilage  to  the  pubic  spine.  It  lies,  on  the  average, 
about  three  inches  laterally  from  the  umbilicus,  and  above  that  level 
it  is  indicated  by  a  shallow  depression  which  ends  above  at  the  margin 
of  the  thorax  in  a  somewhat  triangular  infracostal  fossa. 


THf:  ANTERIOR  ABDOMINAL    WALL.  239 

When  in  action  the  rectus  presents  three  slight  transverse  grooves 
extending  between  the  lineae  alba  and  semilunaris  and  representing  tlie 
lineae  transversse  (see  also  p.  242).  One  is  about  the  tip  of  the  ensiforni 
cartilage,  a  second  midway  between  this  and  the  navel,  the  third,  less 
marked,  at  the  navel  and  occasionally  a  fourth  below  the  navel,  in  the 
outer  half  of  the  muscle. 

The  inguinal  furrow  corresponds  to  Poupart's  ligament,  and  is  an 
important  landmark  in  the  surgical  anatomy  of  hernia. 

Lateral  to  the  linea  semilunaris  the  upper  part  of  the  fleshy  portion 
of  the  e.iicrnal  ohlique  is  seen  interdigitating  with  the  serratus  magnus 
in  a  zigzag  line  directed  obliquely  downward  and  backward.  Its 
prominence  above  the  iliac  crest  forms  the  iliac  furrow  which  lies  over 
the  iliac  crest. 

The  superficial  epigastric  vein  (see  also  p.  249)  is  often  visible  through 
the  skin,  especially  if  enlarged,  when  it  may  be  seen  to  communicate 
with  another  vein  (thoracico-epigastric)  which  joins  the  axillary  vein, 
as  well  as  with  the  superior  epigastric  vein  of  the  internal  mammary. 

THE  ANTERIOR  ABDOMINAL  WALL. 

The  lateral  limits  may  be  taken  to  be  the  lateral  border  of  the 
external  oblique  muscle,  which  alone  of  the  flat  abdominal  muscles  has 
a  free  lateral  margin  between  the  thorax  and  the  iliac  crest.  The  soft 
parts  may  be  studied  by  layers  and  then  certain  important  areas  con- 
sidered separately. 

The  skin  is  thin  and  loosely  attached  to  the  tissues  beneath,  except 
around  the  umbilicus  and,  to  a  less  extent,  in  the  median  line.  In  the 
male  the  skin,  especially  above  the  pubis  and  near  the  median  line, 
is  often  beset  with  hairs.  The  numerous  hair  follicles  may  make  it 
difficult  to  make  the  skin  reasonably  aseptic.  The  cleavage  lines  of 
the  skin  are  in  general  parallel  with  the  course  of  the  lower  intercostal 
and  the  upper  lumbar  nerves.  When  the  skin  has  been  greatly 
stretched  from  abdominal  distension,  scar-like  silvery  streaks  (^sfrice 
gravidarum)  appear,  especially  in  the  lower  part  where  the  distension 
is  usually  greatest.  They  are  due  to  atrophy  of  the  skin  from  stretch- 
ing, but  are  not  evidence  of  pregnancy,  for  they  may  follow  any  great 
distension. 

The  superficial  fascia,  unlike  tlie  subcutaneous  tissue  in  most 
regions,  consists  of  two  layers  which  are  most  distinct  in  the  lower 
half  of  the  abdomen.  Between  the  two  layers  at  the  groin  are  the 
superficial  i^lood  vessels  and  the  oblique  set  of  the  superficial  inguinal 
lymph  nodes.  Both  layers  are  continued  on  to  the  external  genitals 
and  tlie  perineum. 

The  superficial  layer  of  the  superficial  fascia  contains  the  subcu- 
tancatis  Jul,  tlie  deposit  of  which  is  greatest  toward  the  middle  and 
lower  part,  reaching  its  maximum  in  the  female  over  and  about  the 
pubis,  as  the  monx  veneris.  The  fatty  deposit  may  reach  such  a  thirh- 
7Jf'.s'.v(six  inches  has  been  found)  as  to  make  examination  of  the  abdomi- 
nal wall  or  contents  impossible,  and  even  to  eontraindicate  operation. 


240  THE  ABDOMEN. 

The  thicker  the  layer,  the  longer  the  incision  required.  The  fat  of  the 
abdominal  wall  acts  as  a  non-conductor  to  prevent  changes  of  tempera- 
ture affecting  the  viscera  and  thus  serves  as  a  "■  cholera  band."  The 
comparative  thickness  of  the  belly  wall  in  different  subjects  depends  upon 
the  amount  of  this  fat  rather  than  upon  the  thickness  of  the  muscles. 

This  layer  is  continuous  with  the  superficial  fascia  on  all  sides.  In 
thin  subjects  the  fat  may  be  so  small  in  amount  that  not  only  are  the 
muscles  and  superficial  markings  very  clearly  seen,  but  intestinal 
peristalsis  may  be  felt  or  observed  and  visceral  tumors  may  be  readily 
outlined  through  the  thin  wall.  In  very  fat  subjects,  two  deep  folds, 
involving  the  skin  and  this  layer,  run  transversely  across  the  abdomen, 
one  at  the  umbilicus  concealing  it,  and  the  other  just  above  the  pubis. 
Where  the  latter  crosses  the  median  line  the  trocar  should  be  intro- 
duced in  tapping  the  bladder.  These  folds  are  due  to  a  slight  absorp- 
tion of  fat,  due  to  the  pressure  of  the  folding  of  the  skin  in  bending 
forward. 

The  deep  layer  of  the  superficial  fascia  consists  of  a  firm  membrane 
containing  elastic  fibers.  It  is  firmly  attached  to  the  deeper  parts  in 
the  median  line  down  to  the  symphysis  and  to  the  fascia  lata  just 
below  Poupart's  ligament  and  along  the  iliac  crest.  Between  the  sym- 
physis and  the  pubic  spines  it  is  not  attached  to  the  underlying  parts 
but,  uniting  with  the  superficial  layer  which  here  has  lost  its  fat,  it 
passes  down  to  become  continuous  with  the  dartos  of  the  scrotum  and 
penis.  Many  interesting  clinical  facts  depend  upon  this  arrangement. 
Subcutaneous  emphysema  due  to  injuries  of  the  chest,  lipomata,  blood 
or  pus  beneath  this  layer  are  arrested  at  the  median  line,  the  inguinal 
fold  and  the  iliac  crest  and  are  prevented  from  reaching  the  thigh  or 
the  buttock  by  reason  of  its  firm  attachment  to  deeper  parts.  They 
may  however  pass  down  into  the  scrotum  between  the  symphysis  and 
the  pubic  spines.  If  the  same  conditions  occur  superficial  to  this  layer, 
they  may  readily  extend  in  all  directions. 

Tillaux  describes  a  lipoma  beneath  the  deep  layer  in  the  inguinal 
region,  which  was  thought  to  be  an  inguinal  hernia,  but  was  shown 
not  to  be  by  reason  of  the  emptiness  of  the  inguinal  canal. 

In  like  manner  extravasated  urine,  pus  or  blood  in  the  scrotum 
may  ascend  on  to  the  abdomen,  between  the  pubic  spines  and  the 
symphysis,  but  cannot  cross  the  median  line  or  descend  onto  the  thighs 
without  first  perforating  this  layer.  Between  the  two  layers  lie  the 
superficial  vessels,  hence  we  may  remember  in  making  incisions  that 
the  fatty  layer  is  free  from  large  blood  vessels. 

Of  little  surgical  importance,  as  far  as  the  abdomen  is  concerned,  is 
a  /////(  cellular  fa-scia  covering  the  external  oblique  muscle.  In  the 
inguinal  region  this  seems  to  be  continuous  with  the  iutercohonuar 
Jibers  and  the  fascia  which,  binding  them  together,  is  continued 
down  into  the  scrotum  as  the  external  spermatic  fascia,  one  of  the 
coverings  of  the  cord  or  of  an  inguinal  hernia. 

The  muscular  layers  present  vertically  directed  fibers  mesially, 
in  the  rectus  and  pyramidalis  muscles,  and  obliquely  directed  fibers 


PLATE    XXIX 


FIO.  02. 


RECTUS 

ABDOMINAL 


E/E 
TRANSVERS/E 
EXTERNAL 

OBLIQUE 
LINEA    ALBA 


I  NTERNAL 
OBLIQUE 


POUPART'S 
LIGAMENT 

INTERNAL 

ABDOMINAL 
RING 


Muscles,  vessels  and  nerves  of  the  aiitei'ior 
abdomiinal  wall.     (Joessel.) 


MUSCLES  OF  THE  ANTERIOR  ABDOMINAL    WALL.  241 

laterally,  in  the  external  and  internal  oblique  and  transversalis  muscles. 
The  strength  of  the  abdominal  walls  depends  chiefly  upon  the  muscles. 
It  should  be  remeral)ered,  however,  that  these  muscles  are  much 
thinner,  in  most  cases,  tlian  one  would  be  led  to  suppose  from  their 
description  in  text-books. 

The  flat  Jie.shy  bellies  of  the  oblique  muscles  are  found  largely  at  the 
sides,  where  they  fill  in  the  interval  between  the  vertical  muscles  at 
the  back  and  in  front,  except  for  a  narrow  strip  along  the  outer  border 
of  the  rectus  where  tiieir  aponeuroses  form  the  fil)rous  semilunar  line, 
and  a  small  scniilunar  <ire.a  beneath  the  conjoined  tendon. 

T\\Q  fleshy  portion  of  the  external  oblic[ue  terminates  in  a  right  angle, 
readily  seen  in  muscular  subjects  some  distance  from  the  border  of  the 
rectus.  It  lies  above  a  horizontal  line  drawn  from  a  point  on  the 
iliac  crest  one  to  two  inches  behind  the  anterior  superior  iliac  spine, 
and  external  to  a  vertical  line  from  the  lowest  point  of  the  ninth  rib. 
It  also  lies  somewhat  above  a  line  connecting  the  anterior  superior 
iliac  spine  with  the  umbilicus  ;  hence  only  the  upper  part  of  the  usual 
oblique  incisions  in  this  region  involves  the  fleshy  fibers  of  this  muscle. 
It  is  the  only  one  of  the  three  flat  muscles  in  question  which  has  a 
free  posterior  border,  between  its  attachment  to  the  last  rib  and  the 
middle  of  the  iliac  crest,  the  other  two  muscles  being  connected  pos- 
teriorly with  the  luml)ar  fascia.  This  free  lateral  border  may  be 
overlapped  throughout  by  the  latissimus  dorsi,  or  a  triangular  interval 
of  varying  size  may  be  left  between  these  two  muscles  and  above  the 
iliac  crest,  the  triangle  of  Petit,  whose  floor  is  formed  by  the  internal 
oblique.  This  is  a  point  of  least  resistance  where  abscesses  may  point 
or  a  rare  form  of  hernia  may  occur  (lumbar  hernia). 

The  direction  of  the  muscular  and  aponeurotic  fibers  of  the  external 
oblique  is  approximately  at  right  angles  to  the  line  connecting  the 
anterior  superior  iliac  spine  and  the  umbilicus. 

The  fleshy  portion  of  the  internal  oblique  extends  beyond  that  of  the 
external  both  mesially  and  laterally,  and  especially  below  and  mesi- 
ally.  The  loiccr  fibers,  blended  with  those  of  the  transversalis  and 
directed  downward  and  inward,  arch  over  the  inguinal  canal  to  be  in- 
serted into  the  inner  inch  of  the  iliopectineal  line  as  the  conjoined 
tendon.  This  covers  an  area  in  the  inguinal  region  otherwise  wanting 
in  muscular  tissue,  but  leaves  a  narrow  uncovered  space  between  its 
lower  curved  margin  and  the  inner  half  of  Poupart's  ligament  (see 
Inguinal  Region,  pp.  2G0).  The  fleshy  fibers  of  the  internal  obli(pie 
are  directed  in  a  fan-shaped  manner  but,  except  those  forming  the  con- 
joined tendon,  the  general  direction  is  upward  and  inward,  crossing 
those  of  the  external  oblique  nearly  at  a  right  angle,  like  bars  of  lat- 
tice work.  They  do  not  reach  above  a  horizontal  line  drawn  below 
the  tip  of  the  last  rib,  nor  in  front  of  a  line  drawn  upwanl  and  a  little 
outward  from  the  center  of  Poupart's  ligament,  except  for  the  con- 
joined tendon. 

The  fleshy  flbers  of  the  transversalis,  directed  for  the  most  part  trans- 
versely, ])resent  mesially  a  concave  margin,  approaching  nearer  the 
16 


242  THE  ABDOMEN. 

middle  Hue  above  and  below.  The  upper  fibers  pass  beneath  the 
rectus  and  therefore  underlie  the  semilunar  line  in  the  upper  part, 
the  lower  Jibcrs  take  part  in  forming  the  conjoined  tendon  but  arch 
high  above  the  inguinal  canal  and  give  no  covering  to  the  cord  or  a 
hernia,  as  does  the  internal  oblique  by  means  of  the  cremasteric  fascia. 

These  three  flat  abdominal  muscles  are  separated  from  one  another 
by  a  certain  amount  of  loose  connective  tissue,  which  favors  the  spread 
of  inflammation  from  a  wound.or  of  a  mural  absce,%^  from  spinal  caries, 
etc.  Such  abscesses  will  be  limited  by  the  semilunar  line  mesially, 
the  erector  spinal  laterally,  Poupart's  ligament  below,  and  the  bony 
thorax  above,  and  usually  work  down  to  the  iliac  crest,  the  inguinal 
fold,  or  along  the  inguinal  canal  into  the  scrotum  or  labia. 

Between  the  internal  oblique  and  transversalis  muscles  run  the  main 
trunks  of  the  lower  thoracic  and  the  upper  lumbar  nerves  that  supply 
the  muscles  and  skin  of  the  abdomen. 

The  different  direction  and  the  crossing  of  the  fibers  of  the  oblique 
and  transversalis  muscles  has  the  following  jj/v/ef/ca/  results:  (1)  It 
strengthens  the  abdominal  wall  and  greatly  reduces  the  possibility  of 
a  liernia  between  the  separated  fibers  of  the  muscles.  (2)  It  permits 
contraction  of  the  abdominal  wall  in  every  direction  and  thus,  (3)  in- 
creases the  amount  of  abdominal  pressure  for  the  expulsion  of  urine, 
faeces,  and  the  foetus.  (4)  It  produces  greater  approximation  in  the 
movements  of  the  movable  bony  boundaries  of  the  abdomen.  (5)  It 
affords  a  landmark  or  an  index  as  to  the  depth  of  an  incision  in 
operations. 

Before  studying  the  aponeuroses,  or  tendons,  of  the  above  muscles  it 
is  convenient  to  consider  the  vertical  muscles,  the  rectus  and  pyriformis. 

The  two  recti  run  vertically  the  entire  length  of  the  abdominal 
parietes  on  either  side  of  the  median  line.  They  are  much  narrower 
below  than  above,  and  in  the  upper  two  thirds  are  said  to  be  about  as 
broad  as  the  hand,  at  the  heads  of  the  metacarpal  bones.  The  longi- 
tudinal fibers  are  interrupted  by  the  fibrous  intersections  at  the  lineae 
tranversae,  so  that  they  do  not  run  the  entire  length  of  the  muscle. 
The  linefe  transversse  represent  the  septa  which  divide  the  muscles  of 
the  abdomen  at  intervals  in  the  lower  vertebrates  and  the  abdominal 
ribs  of  the  crocodile.  The  latter  analogy  is  indicated  by  the  relation 
of  some  of  the  lower  thoracic  nerves  to  the  intersections,  similar  to  that 
of  these  nerves  to  the  ribs.  The  intersections  serve  the  important 
function  of  holding  together  the  fibers  of  the  muscle  and  preventing  the 
formation  of  ventral  hernia  in  cases  of  great  abdominal  distension  from 
pregnancy,  etc.,  but  they  do  not  offer  serious  resistance  to  the  longi- 
tudinal separation  of  the  fibers  in  a  vertical  incision  through  the  rectus. 
They  prevent  the  extensive  retraction  after  division  of  the  muscle  which 
would  result  if  the  fibers  were  uninterrupted.  Resembling  as  they  do 
transverse  scars  they  indicate  that  transverse  incisions  of  this  muscle, 
if  healed  by  a  proper  cicatrix,  only  increase  the  number  of  such  trans- 
verse intersections  which  nature  provides  to  strengthen  the  muscle  and 
therefore  can  do  no  harm.     These  fibrous  intersections  are  adherent  to 


POUP ART'S  LIGAMENT.  243 

the  front  but  not  to  the  back  of  the  sheath  of  the  rectus ;  hence  sup- 
pwdtion  in  the  rectus  may  be  liiaifcd  to  the  interval  between  two  trans- 
verse intersections,  or  below  the  lower  one,  though  it  may  extend  along 
the  entire  dorsal  surface  where  they  are  not  connected  with  the  sheath. 

By  means  of  this  connection  of  the  intersections  with  the  sheath, 
the  action  of  the  rectus  may  affect  the  latter  and  the  aponeuroses  of 
which  it  is  formed,  thus  diffusing  its  action.  They  allow  part  of  the 
muscle  to  act  at  a  time,  as,  for  example,  the  lower  part  in  micturition. 

Similarly  the  rectus  may  be  the  seat  of  a  form  of  phantom  tumor 
in  hysterical  subjects,  due  to  a  contraction  of  a  part  of  the  muscle, 
usually  to  a  segment  between  two  intersections.  The  irregular  con- 
traction of  other  abdominal  muscles  may  also  cause  a  phantom  tumor. 
When  associated  with  distension  of  the  bowels  from  flatus  or  fteces 
and  with  abdominal  or  pelvic  symptoms  such  tumors  may  mislead. 
The  relaxation  of  the  contraction  from  an  anaesthetic,  or  otherwise, 
causes  the  tumor  to  disappear.  They  are  said  to  be  more  common  in 
the  left  rectus.  The  position  of  the  intersections  has  already  been  given. 
(See  page  239.) 

The  fibers  of  the  rectus  are  rarely  torn  by  muscular  violence  and  in 
opisthotonos. 

Below  the  umbilicus  the  two  reeti  are  so  close  together  that  it  is 
scarcely  possible  to  make  a  median  incision  without  exposing  the 
mesial  fibers  of  one  or  both. 

The  pyxamidalis  muscles  lie  beneath  the  sheath  of  the  recti,  in  front 
of  the  latter  muscles  and  separated  from  them  by  a  layer  of  fibrous 
tissue.  They  are  inserted  into  the  linea  alba  one  third  to  one  half 
the  distance  between  the  symphysis  and  the  umbilicus  and,  when  large, 
may  entirely  cover  the  median  line,  so  that  division  of  their  fleshy  fibers 
cannot  be  avoided  in  a  median  incision.  They  may  be  absent  or 
unusually  small  on  one  or  both  sides. 

The  anterior  aponeuroses  of  the  oblique  and  transversalis  mus- 
cles extend  from  the  mesial  borders  of  the  fleshy  portion  of  these  mus- 
cles to  the  median  line,  where  they  unite  with  those  of  the  opposite  side 
to  form  the  linea  alha.  Thus  the  transversalis  muscles  of  the  two  sides 
may  be  considered  a  double-bellied  muscle  with  an  intervening  tendon, 
and  the  same  may  be  said  of  the  external  oblique  on  one  side  with  the 
internal  oblique  of  the  opposite  side,  for  their  fibers  run  in  a  similar 
direction.  The  aponeurosis  of  the  external  oblique  is  widest  below, 
that  of  the  internal  ol)lique  above,  and  that  of  the  transversalis  in 
the  middle. 

The  inguinal  or  Poupart's  lig-ament  is  formed  of  the  thickened 
lower  fibers  of  the  aponeurosis  of  the  external  oblique  which  extend 
from  the  anterior  superior  iliac  spine  to  the  pubic  spine. 

Beneath  It  the  ilio-psoas  muscle,  the  femoral  vessels,  the  anterior 
crural,  the  external  cutaneous,  and  the  crural  branch  of  the  genito-crural 
nerves,  together  with  the  lymphatics  pass  from  the  pelvis  into  the 
thigii.  It  is  somewhat  infolded  on  itself  so  as  to  form  a  kind  of  gutter, 
the  concavity  of  which  is  directed  upward  and  inward  and  the  dorsal 


244:  THE  ABDOMEN. 

margin  of  which  is  loosely  coimected  with  the  transversalis  fascia  and, 
in  the  outer  part,  with  the  iliac  fascia  also.     (Fig.  63.) 

Inferiorly  it  is  firmly  connected  with  the  fascia  lata  of  the  thigh 
which,  in  the  extended  position  of  the  hip,  pulls  it  downward  so  as  to 
make  it  convex  dowmrard.  Hence  in  palpation  of  the  abdomen,  as  well 
as  in  the  reduction  of  hernia,  the  thighs  are  flexed  on  the  })elvis  which 
relaxes  the  traction  of  the  fascia  lata  on  Poupart's  ligament.  This 
relaxes  the  abdominal  walls  by  relaxing  the  aponeurosis  of  the  exter- 
nal oblique  and  the  transversalis  fascia,  as  well  as  the  internal  oblique 
and  transversalis  muscles  which  arise  from  the  outer  half  of  Poupart's 
ligament.  In  addition,  the  stomach,  bowels  and  bladder  should  be 
empty  to  facilitate  palpation. 

Poupart's  ligament  corresponds  to  the  inguinal  fold,  and  is  an  im- 
portant landmark  in  the  surgical  anatomy  of  hernia,  as  well  as  in 
the  operations  performed  in  the  iliac  region  of  the  abdominal  pari- 
etes.  Some  of  its  fibers  pass  nearly  directly  backward  to  be  attached 
to  the  inner  inch  or  so  of  the  ilio-pubic  line.  These  form  Gimbeniat's 
lif/atnent  whose  free,  concave,  external  margin  is  at  the  inner  border 
of  the  crural  canal  (see  p.  271).  The  latter  ligament  forms  part  of  the 
septum  between  the  pelvis  and  the  thigh.  Upon  the  concave  upper 
surface  of  Poupart's  ligament  lie  the  structures  which  pass  out  at  the 
external  abdominal  ring. 

Internal  to  the  pubic  spine  the  fibers  of  the  external  oblique  apo- 
neurosis are  attached  to  the  crest  of  the  pubes.  But  some  of  its  fibers, 
known  as  the  triangular  ligament  or  fascia,  decussating  with  fibers  of 
the  aponeurosis  of  the  opposite  side,  cross  the  median  line,  pass  be- 
hind and  strengthen  the  opposite  external  abdominal  ring  and  are 
attached  to  the  pubic  crest  and  the  ilio-pectineal  line  of  that  side,  in 
connection  with  Gimbernat's  ligament. 

The  tendinous  fibers  of  insertion  of  the  conjoined  tendon  are  inserted 
into  the  ilio-pectineal  line  behind  Gimbernat's  and  the  triangular 
ligaments.  This  tendon  lies  behind  the  external  abdominal  ring, 
strengthening  an  otherwise  weak  spot. 

The  semilunar  line  (see  also  p.  238)  indicates  the  line  along  which 
the  abdominal  aponeuroses  divide  to  form  the  sheath  of  the  rectus. 
Along  this  line,  lying  between  the  rectus  and  the  fleshy  portion  of  the 
lateral  muscles,  the  abdominal  wall  is  composed  only  of  the  fibrous  tissue 
of  the  abdominal  aponeuroses,  except  above  where  fleshy  fibers  of 
the  transversalis  pass  behind  it.  It  is  devoid  of  large  vessels,  except 
low  down  where  the  deep  epigastric  vessels  cross  it,  hence  it  is  some- 
times chosen  for  incision  or  paracentesis. 

It  is  concave  mesially  corresponding  to  the  outer  border  of  the  rectus. 
The  upper  end  of  the  line  is  at  or  slightly  internal  to  the  point  where 
the  gall-bladder  comes  in  contact  with  the  abdominal  wall.  Above  a 
level  1|  inches  below  the  umbilicus,  the  semilunar  lines  nearly  cor- 
respond to  vertical  lines  erected  from  the  middle  of  Poupart's  liga- 
ment. "  3IcBurnei/'s  Point"  is  on  the  semilunar  line  where  it  is 
crossed  by  the  line  connecting  the  anterior  superior  iliac  spine  with 


PLATE    XXX. 


FIG.  68. 


SUPERFICIAL    LAYER 
SUPERFICIAL    FASCIA 


DEEP    LAYER,   SUPER 
FICIAL    FASCIA 


EXT.    OBLIQUE 
APONEUROSIS 


TRANSVERSALIS 

MUSCLE 
INT.    OBLIQUE 

MUSCLE 
TRANSVERSALIS 

FASCIA 
PERITON  EUM 


lAC    FASCIA 


UBPERITONEAL- 
TISSUE 


FASCIA    LATA 


Sagittal  section  of  anterior  abdominal  wall   through  the 
outer  half  of  Poupart's  ligament.     (Tillaux.) 


FIG.   64. 


SHEATH    OF 
RECTUS 


SUPERFICIAL 
FASCIA 


EXTERNAL 
OBLIQUE 


NSVERSAL 
FASCIA 


PERITONEUM 


Diagrammatic  transverse  section  of  anterior  abdominal 
wall.  Upper  figure  above,  lower  figure  below  the  semi- 
lunar fold  of  Douglas.     (Joessel.) 


THE  LINE  A    ALBA.  245 

the  umbilicus.  This  point  corresponds  about  to  the  base  of  the 
appendix. 

The  sheath  of  the  rectus  (Fig.  04)  h  formed  hij  the  aponeuroses  of 
the  three  lateral  muscles.  That  of  the  internal  oblique  splits  along  the 
semilunar  line  to  pass  partly  in  front  and  partly  behind  the  muscle. 
This  arrangement  holds  in  the  upper  three  fourths  of  the  muscle,  but 
in  the  lower  fourth,  a  little  above  midway  between  the  umbilicus  and 
the  symphysis,  all  three  aponeuroses  pass  in  front.  The  lower  limit 
of  the  dorsal  part  of  the  sheath  formed  by  the  aponeuroses  is  concave 
downward,  and  known  as  the  semilunar  fold  of  Douglas.  Below  this 
a  delicate  fascia  is  described  as  passing  down  behind  the  rectus  to  the 
bladder  {^faxcia  lidzii),  in  addition  to  the  tran.wersalis  fciscia  which  is 
here  firm  and  thickened  and  takes  the  place  of  the  dorsal  layer  of  the 
sheath. 

At  the  fold  of  Douglas  the  deep  epUjaxiric  vessels  pass  within  the 
rectus  sheath  in  their  upward  course.  The  lateral  extremities  of  the 
folds  of  Douglas  descend  as  thickened  bands  or  pillars,  the  inner  pillar 
to  the  symphysis,  the  outer,  or  ligament  of  Hesselbach  (Braune),  splits 
to  enclose  the  internal  abdominal  ring,  being  attached  internally  to  the 
horizontal  ramus  of  the  pubis  (and  to  the  pectineal  fascia),  and  exter- 
nally to  the  iliac  fascia  (over  the  psoas)  and  to  the  transversalis  muscle 
where  it  arises  from  Poupart's  ligament. 

The  aponeurotic  layers  which  form  the  ventral  and  dorsal  layers 
of  the  sheaths  of  the  recti  uniting  along  the  median  borders  of  the 
muscles  to  complete  the  sheaths  join  one  another  to  form  a  median 
fibrous  raphe,  the  linea  alba  (see  also  p.  238).  From  the  ensiform 
cartilage  to,  and  a  little  below  the  umbilicus  it  is  wide,  apparent  and 
easily  found,  measuring  about  |  inch  in  width  below  the  ensiform  carti- 
lage and  5  inch  near  the  umbilicus.  Belo\v  the  umbilicus  it  rapidly 
narrows,  and  thence  down  to  the  symphysis  it  is  merely  the  narrow 
fibrous  interval  between  the  sheaths  of  the  two  recti  where  their  sheaths 
coalesce.  This  fibrous  interval  may  be  difficult  to  find,  and  in  fact  it 
may  be  said  that  (here  is  practically  no  linea  alba  below  the  umbilicus, 
and  that  it  is  rarely  possible  to  incise  here  without  exposing  the  margins 
of  one  or  both  recti  muscles,  so  that  the  knife  need  only  follow  the 
median  line  and  disregard  the  linea  alba.  Just  above  the  symphysis 
the  linea  alba  expands  into  a  narrow  triangular  band,  the  adminiciilum, 
only  visible  on  the  dorsal  surface  of  the  abdominal  wall.  The  interval 
between  the  two  muscles  is  slightly  more  marked  just  above  the  sym- 
physis in  front  also,  so  that  it  has  been  suggested  to  incise  from  below 
upwards  in  this  part  of  the  linea  alba,  for  the  reason  that  it  may  be 
more  easily  found. 

In  ])regnancy  or  in  abdominal  distension  from  other  causes  the 
linea  alba  becomes  much  wider,  owing  to  the  separation  of  the  recti, 
reaching  3|  inches  at  the  umbilicus  and  1-^  inches  at  the  narrowest 
part  (Cruveillier).  I  have  also  observed  a  congenital  separation  of 
the  recti  with  a  corresponding  widening  of  the  linea  alba  and  a  slight 
umbilical   hernia   in   an    otherwise  healthy  tliild.      The   fingers  could 


246  THE  ABDOMEN. 

readily  be  thrust  between  the  recti,  below  the  iirabiliciis.  A  similar 
condition  may  exist  in  "pot-bellied,"  rickety  children.  In  such  cases 
a  ventral  hernia  may  occasionally  occnr  between  the  two  recti  muscles. 
Ventral  hernia  of  the  linea  alba  is  usually  due  to  the  enlargement  of 
small  openings  which  exist  normally,  some  of  them  for  the  passage  of 
small  nerves  and  vessels.  Such  a  hernia  should  not  be  confounded 
with  small  lipomata  which  may  grow  from  the  subperitoneal  tissue 
through  these  openings. 

The  fibrous  tissue  composing  the  linea  alba  is  thin  and  compact, 
and  cannot  be  separated  into  layers  corresponding  to  the  three  apon- 
euroses which  unite  from  either  side  to  form  it.  As  there  are  no  ves- 
sels of  any  size  in  the  linea  alba  it  is  often  selected  for  incision  or 
paracentesis. 

Contraction  of  the  muscles  of  the  abdominal  wall  make  the  latter  as 
hard  as  a  board.  In  this  condition  they  protect  the  viscera  within  from 
sudden  movement  or  pressure  in  acute  peritonitis,  or  from  a  blow.  If 
a  blow  is  expected  the  instinctively  contracted  and  rigid  abdominal 
muscles  protect  the  viscera  from  injury  like  a  firm  but  elastic  rubber 
plate,  though  they  themselves  may  be  bruised  or  even  torn.  On  the 
contrary  an  unexpected  blow  upon  a  flaccid  abdomen  may  seriously 
wound  a  viscus  without  visibly  affecting  the  belly  wall,  the  latter 
escaping  injury  by  being  very  freely  movable  over  the  viscera.  It  is 
impossible  to  tell  the  severity  of  the  blow  or  the  seriousness  of  the 
injury  from  outward  inspection.  In  such  cases  a  thick  padding  of  fat 
in  the  belly  wall  or  omentum  helps  to  protect  the  viscera  from  injury. 

On  account  of  the  tonic  contraction  of  the  abdominal  muscles  a  posi- 
tive pressure  [intra-abdominal  pressure)  normally  exists  in  the  abdomen, 
and  this  pressure  is  increased  by  the  descent  of  the  diaphragm  in  in- 
spiration. For  this  reason  the  abdominal  viscera  readily  protrude 
through  a  penetrating  wound  of  the  belly  wall.  Diminution  of  this 
pressure  and  weakness  of  the  muscles  which  cause  it  is  an  impor- 
tant element  in  constipation,  difficult  labor,  pelvic  displacements  in 
women,  etc. 

The  transversalis  fascia,  not  to  be  confounded  with  the  trans- 
versalis  aponeurosis,  lines  the  deep  surface  of  the  transversalis  muscles 
and  their  anterior  aponeuroses,  and  is  continuous  with  the  fascia  lining 
the  other  parts  of  the  abdominal  walls. 

It  is  very  thin  above  the  umbilical  level,  where  it  passes  up  to  be- 
come continuous  with  a  delicate  fascia  on  the  under  surface  of  the  dia- 
phragm and  laterally  it  is  continuous  with  the  anterior  layer  of  the 
lumbar  fascia.  Below  the  umbilicus  it  becomes  thicker  and  firmer  as 
we  trace  it  downward,  and  here  it  is  important  in  strengthening  the 
abdominal  wall  where  the  tendency  to  hernia  is  greatest.  This  is  espe- 
cially so  mesially,  where  it  supplies  the  place  of  the  posterior  sheath 
of  the  rectus  below  the  semilunar  fold  of  Douglas,  and  laterally  be- 
tween the  inner  half  of  Poupart's  ligament  and  the  conjoined  tendon, 
where  it  is  very  strong  and  strengthens  an  otherwise  weak  spot. 

It  is  attached  to  the  inner  lip  of  the  iliac  crest  and  to  the  outer  half 


THE  SUBPERITONEAL  CONNECTIVE  TISSUE.  247 

of  Poupart's  ligament,  blending  with  the  iliac  fascia.  Beneath  the 
inner  half  of  Poupart's  ligament,  to  which  it  is  but  loosely  attached,  it 
is  thickened  by  transverse  fibers  to  form  the  deep  femorul  (irdt,  and  is 
continued  down  into  the  thigh  to  form  the  front  of  the  fcmordl  sheath. 
More  internally  it  is  attached  to  the  iliopectineal  line,  behind  the  con- 
joined tendon,  and  to  the  crest  of  the  pubes,  where  it  is  continuous 
with  the  pelvic  fascia. 

i,  In  the  male,  a  pouch  of  this  fascia  shaped  like  a  funnel,  hence 
called  the  infundibuliform  fascia,  descends  in  fcetal  life  with  the  peri- 
toneal processus  vaginalis  along  the  inguinal  canal  into  the  scrotum, 
forming  one  of  the  coverings  of  the  spermatic  cord  and  the  testis. 
After  the  descent  of  the  testis  this  pouch  contracts,  so  that  it  closely 
surrounds  the  cord  in  its  passage  through  the  inguinal  canal,  leaving  a 
slight  depression  with  a  crescentic  mesial  border  at  the  internal  ring, 
where  the  fascia  is  called  infundibuliform.  As  the  transversalis  fascia 
lines  the  antero-lateral  abdominal  walls,  no  hernia  can  occur  here  with- 
out receiving  a  covering  from  it. 

In  incisions  this  fascia  may  possibly  be  mistaken  for  the  peritoneum, 
and  the  subperitoneal  fat  beneath  it  for  the  underlying  omentum. 

This  fascia  will  direct  the  course  of  an  abscess,  etc.,  lying  superficial 
to  it.  Such  an  abscess  would  be  disposed  to  spread  downward  where 
it  would  be  checked  by  and  point  above  the  attachment  of  the  fascia 
to  the  iliac  crest  and  the  outer  half  of  Poupart's  ligament,  or  more 
internally  it  might  run  along  the  inguinal  canal  into  the  scrotum. 

The  subperitoneal  connective  tissue  is  a  delicate  layer  of  loose 
connective  tissue  containing  a  varying  amount  of  fat,  which  separates 
the  parietal  peritoneum  from  the  fascia  lining  the  abdominal  walls. 

Along  the  linea  alba  and  at  the  umbilicus  it  binds  the  transversalis 
fascia  and  peritoneum  closely  together.  Elsewhere  it  is  more  loose 
and  abundant,  and  its  looseness  favors  the  spread  of  abscess,  etc.,  on 
the  one  hand,  and  on  the  other  hand  allows  the  peritoneum  to  be 
stripped  up  from  the  fascia  in  extraperitoneal  operations  on  the  iliac 
vessels,  ureter,  etc. 

Owing  to  the  ease  with  which  this  tissue  allows  the  peritoneum  to 
be  stripped  up  care  is  required  to  avoid  this  in  abdominal  incisions  and 
especially  in  operations  for  ovarian  cysts,  where  the  peritoneum  may 
be  mistaken  for  the  cyst  wall  and  extensively  detached.  In  abdominal 
incisions  it  is  often  best  to  fasten  the  peritoneum  to  the  overlying 
layers  by  a  suture  or  two,  so  that  the  manipulations  through  the  wound 
will  not  strip  it  up.  The  presence  of  this  tissue,  especially  when  thick 
or  containing  fat,  is  useful  as  a  landmark  in  abdominal  incisions  to 
indicate  that  the  peritoneum  has  been  reached.  It  should  be  borne  in 
mind  that,  in  some  cases  and  localities,  the  amount  of  fat  may  be  con- 
siderable so  as  not  to  mistake  it  for  the  omentum,  as  sometimes  hap- 
pens. The  amount  of  fat  is  greatest  in  the  inguinal,  iliac,  and  lumbar 
regions,  in  the  latter  furnishing  the  perinephritic  fat. 

It  serves  to  connect  those  viscera  having  an  incomplete  or  imperfect 
peritoneal  covering  with  the  abdominal  parietes,  and   in   such  places 


248  THE  ABDOMEN. 

supports  a  delicate  anastomosis  between  the  parietal  and  visceral  ves- 
sels, as  in  the  liver,  kidneys,  pancreas,  duodenum,  vertical  parts  of 
the  colon,  rectum,  bladder,  etc. 

Inflammations  may  extend  from  these  organs  into  this  tissue  where 
it  readily  spreads,  usually  in  the  direction  of  gravity.  Thus  an-  ab- 
scess from  a  neglected  appendicitis  may  extend  in  the  subperitoneal 
tissue  of  the  iliac  fossa  to  Poupart's  ligament,  where  it  may  displace 
upward  the  parietal  peritoneum  and  form  a  large  abscess  that  can  be 
opened  without  opening  the  peritoneum,  as  was  done  before  the  modern 
operation  for  appendicitis. 

The  looseness  of  this  tissue  allows  the  upward  displacement  of  the 
parietal  peritoneum  just  above  the  symphysis  when  a  distended  blad- 
der rises  out  of  the  pelvis,  and  thus  permits  the  extraperitoneal  tap- 
ping or  opening  of  the  bladder.  In  front  of  the  bladder  it  is  rich  in 
fat  and  forms  the  loose  tissue  of  the  "  Cavum  Retzii."  At  the  upper 
end  of  the  crural  canal  it  forms  the  septum  crurale,  and  it  descends 
along  the  inguinal  canal  to  form  a  delicate  covering  of  the  cord,  the 
testis  or  a  hernia.  Its  adipose  tissue  is  the  starting  point  of  subserous 
Upomata,  which  may  also  push  through  small  openings  of  the  over- 
lying parts,  as  in  the  linea  alba,  and  simulate  a  hernia. 

At  the  internal  abdominal  ring,  especially  on  its  inner  side,  this 
tissue  contains  a  considerable  amount  of  fat  which,  if  it  be  absorbed  or 
diminished  from  any  cause,  may  leave  a  depression  which  favors  the 
formation  of  hernia. 

A  rare  form  of  properitoneal  hernia  may  occur  in  this  tissue,  i.  e., 
between  the  peritoneum  and  the  transversalis  fascia.  The  subperito- 
neal connective  tissue  forms  a  perivascular  sheath  for  the  large  vessels 
which  lie  in  it,  and  accompanies  them  outside  the  abdomen. 

The  Parietal  Peritoneum  is  described  later  ;  see  p.  284. 

Vessels  and  Nerves  of  the  Anterior  Abdominal  Wall. 

Arteries. — The  superficial  arteries  (superficial  epigastric  and  cir- 
cumflex iliac)  are  branches  of  the  femoral  and  lie  between  the  layers 
of  the  superficial  fascia.  They  are  of  little  importance,  although  Ver- 
neuil  has  reported  a  case  of  bleeding  from  the  superficial  epigastric 
resulting  fatally. 

Of  the  deep  arteries,  the  deep  epigastric,  a  branch  of  the  external 
iliac,  is  the  most  important.  Where  it  reaches  the  anterior  abdominal 
wall,  just  above  Poupart's  ligament,  it  lies  behind  the  inguinal  canal, 
just  internal  to  the  internal  abdominal  ring  and  a  little  above  and  to 
the  outer  side  of  the  femoral  ring.  The  vas  deferens  in  the  male,  and 
the  round  ligament  in  the  female,  loop  over  it  just  internal  to  the  in- 
ternal ring  and  draw  it  slightly  inward.  Its  direction  may  be  marked 
off  by  a  line,  slightly  curved  inwards,  from  the  outer  end  of  the  inner 
third  of  Poupart's  ligament  to  a  point  an  inch  or  so  external  to  the 
umbilicus.  In  this  line  paracentesis  should  not  be  performed,  for 
hemorrhage  from  this  artery  might  be  free  in  the  loose  tissue  in  which 
it  lies  inferiorly. 


VESSELS  OF  THE  ANTERIOR  ABDOMINAL    WALL.  249 

In  its  course  it  lies  at  first  lateral  to  the  rectus  and  then  behind  it. 
At  first  it  is  embedded  in  the  subperitoneal  connective  tissue,  then  it 
pierces  the  transversalis  fascia  and,  ])assing  within  the  sheath  of  the 
rectus  at  the  fold  of  Douglas,  it  lies  behind  the  rectus,  midway  between 
its  borders,  and  finally  within  the  muscle  where  it  anastomoses  with  the 
superior  epigadric  branch  of  the  internal  mammary  artery. 

Besides  the  latter  artery,  small  branches  derived  from  the  two  lower 
intercostals,  the  lumbar  and  the  circumflex  iliac  arteries  are  found  in 
the  abdominal  parietes.  No  artery  of  the  antero-lateral  abdominal 
parietes  is  of  such  size  or  importance  as  alone  to  contraindicate  a 
given  incision,  but  it  is  well  to  bear  in  mind  the  course  of  the  deep 
epigastric  artery  and  that  it  crosses  the  semilunar  line. 

Veins. — The  deep  set  of  veins  are  the  paired  vence  comiles,  accom- 
panying the  deep  arteries,  in  like  manner  with  which  they  anastomose 
with  one  another  as  well  as  with  a  plexus  in  the  parietal  peritoneum 
and  a  purain/jilical  vein  which,  passing  along  the  round  ligament  of 
the  liver  to  that  organ,  connects  the  portal  veins  with  the  deep  epi- 
gastric. 

The  subcutaneous  or  superficial  set  are  single  and  do  not  exactly  fol- 
low the  corresponding  arteries.  The  superficial  epigastric  vein  is  often 
seen  through  the  skin.  It  anastomoses  with  the  deep  and  the  superior  epi- 
gastric and  thereby  with  the  parumbilical  and  portal  veins,  and  also 
with  a  subcutaneous  vein  (r.  thoracieo-epigastrica)  which  runs  up  the 
side  of  the  thorax  to  join  the  axillary  vein.  This  thoracico-epigastric 
vein  may  be  continued  independently  into  the  temoral  instead  of  or  as 
well  as  joining  the  superficial  epigastric. 

The  surface  veins  may  become  enormously  dilated  or  varicose,  to  the 
size  of  the  little  finger,  and  so  become  very  distinct.  This  conditi(»n 
(caput  meduste)  usually  depends  upon  their  aifording  a  collateral  circu- 
lation in  obstruction  of  the  inferior  cava  or  the  portal  veins,  although 
this  varicosity  may  exist  without  any  such  obstruction  and,  vice  versa, 
the  obstruction  may  exist  without  any  varicosity. 

Although  it  has  been  shown  from  the  arrangement  of  valves  that 
the  current  in  these  surface  vessels  above  the  navel  is  toward  the  axilla, 
and  in  those  below,  toward  the  groin,  yet  when  the  veins  are  dilated 
the  valves  become  insufficient  and  the  current  can  take  an  abnormal 
course.  In  portal  obstruction  the  curi'ent  in  the  superficial  epigastric 
is  toward  the  groin,  where  it  empties  into  the  femoral  or  the  internal 
saphenous,  and  in  caval  obstruction  the  current  is  in  the  reverse  direc- 
tion and  passes  into  the  axillary  through  the  thoracico-epigastric  vein. 

The  direction  of  the  current  is  determined  by  emptying  the  veins 
and  allowing  them  to  fill  and  is  a  point  that  may  be  utilized  in 
diagnosis. 

Lymphatics. — As  to  the  superficial  lymphatics,  those  above  the  level 
of  the  umbilicus  go,  with  those  of  the  breast,  to  the  axillary  nodes; 
those  below  this  level,  to  the  inguinal  nodes. 

Little  is  known  of  any  deep  li/niphatic^,  but  they  probably  accom- 
pany the  vessels  to  the  iliac  and  sternal  glands. 


250  THE  ABDOMEN. 

Nerves. — The  nerves  supplying  tlie  antero-lateral  abdominal  wall  are 
the  lower  thoracic  nerves,  and  the  iliohypogastric  and  ilioinguinal 
branches  of  the  first  lumbar  nerve.  The  sensory  supply  of  the  skin  is 
furnished  by  the  anterior  divisions  of  the  lateral  cutaneous  branches 
and  the  anterior  cutaneous  branches  of  the  lower  seven  thoracic  nerves 
and  by  the  hypogastric  branch  of  the  iliohypogastric  nerve. 

The  sixth  and  seventh  nerves  supply  the  skin  over  the  "  pit  of  the 
stomach,"  the  eighth  nerve  corresponds  to  the  middle  linea  transversa, 
the  tenth  to  the  umbilicus,  the  distribution  of  the  twelfth  (or  subcostal) 
extends  to  within  two  inches  of  the  symphysis,  that  of  the  iliohypogas- 
tric is  below  this. 

The  muscles  of  this  region  of  the  abdominal  parietes  are  ■'supplied  by 
branches  from  the  same  nerves,  with  the  exception  of  the  sixth  thoracic 
and  the  addition  of  a  few  filaments  from  the  ilioinguinal  nerve. 

The  anterior  port ion--<  of  these  nerves  ji)a.?.s-  between  the  transversalis 
and  internal  oblique  muscles  to  the  outer  border  of  the  sheath  of  the 
rectus,  which  they  pierce  to  supply  the  muscle,  within  which  they  give 
off"  the  anterior  cutaneous  branches.  The  fact  that  these  numerous 
nerves  supply  the  abdominal  muscles,  makes  their  position  and  direc- 
tion of  importance  in  planning  incisions. 

These  nerves  are  placed  at  fairly  equal  distances  apart,  and  pjass 
downward  and  inward  in  the  lower  third  of  the  ventral  abdominal  wall. 
(/.  e.,  the  eleventh  and  twelfth  thoracic,  the  iliohypogastric  and  the 
ilioinguinal  nerves),  nearly  transversely  inward  in  the  middle  third 
(i.  e.,  ninth  and  tenth  thoracic  nerves),  and  somewhat  upward  and  in- 
ward in  the  upper  third  (/.  e.,  the  seventh  and  eighth  thoracic  nerv^es). 

According  to  Brewer  the  course  of  the  twelfth  thoracic  nerve  is  indi- 
cated by  a  line  from  a  point  half  an  inch  below  the  tip  of  the  twelfth 
rib  to  the  spine  of  the  pubis  on  the  opposite  side  ;  that  of  the  eleventh 
thoracic  nerve  by  a  line  from  a  point  half  an  inch  below  the  tip  of  the 
eleventh  rib  to  the  middle  of  Poupart's  ligament  on  the  opposite  side, 
that  of  the  tenth  thoracic  nerve  from  a  point  half  an  inch  above  the  tip 
of  the  eleventh  rib  to  the  anterior  superior  spine  of  the  opjjosite  side. 
The  line  indicating  the  course  of  the  ninth  nerve  is  from  a  point  just 
below  the  osteochondral  junction  of  the  ninth  rib  horizontally  inward, 
that  for  the  eigldh  thoracic  nerve  is  from  a  point  just  below  the  outer 
end  of  the  eighth  cartilage  horizontally  inward  to  a  point  half  an  inch 
to  the  median  side  of  the  chondral  border  and  then  upward  and  inward 
parallel  with  the  border  and  half  an  inch  internal  to  it.  In  great 
abdominal  distension  or  obesity  these  lines  would  not  hold. 

The  lower  nerves  run  somewhat  more  transversely  than  the  fibers 
of  the  external  oblique  and  its  aponeurosis,  so  that  they  are  in  some 
danger  of  injury  even  by  oblique  incixions  parallel  to  these  fibers,  as  in 
operations  for  appendicitis,  but  they  may  be  spared  with  a  little  care. 
Vertical  incisions  of  any  length,  save  in  or  near  the  median  line,  can- 
not av^oid  exposure  and  division  of  one  or  more  of  these  nerves. 
Division  of  these  nerves  results  in  a  paresis  of  that  part  of  the  abdomi- 
nal muscles  which  is  supplied  by  the  nerves  concerned,  and  this  paresis 


THE  NERVES  OF  THE  ABDOMINAL    WALL.  251 

causes  a  weakness  and  bulging  of  the  abdominal  walls  and  increases 
the  tendency  to  hernia.  The  direction  of  the  nerves  is  nearly,  if  not 
quite,  parallel  to  the  cleavage  lines  of  the  skin. 

An  inflammation  {perineuritis)  of  one  or  more  of  these  nerves  causes 
pain  in  the  area  of  distribution,  and  may  be  accompanied  or  followed 
by  a  vesicular  cutaneous  eruption  limited  to  the  same  area  and  known 
as  herpes  zoster  [^(oazr^n — a  girdle),  or  shingles.  Pain  or  modified  sen- 
sation (a  sense  of  constriction  or  tightness)  in  the  area  of  distribution 
may  also  be  caused  by  pressure  on  the  nerve  trunk  where  it  emerges 
from  the  spine,  and  is  due  to  an  injury  or  to  the  s])inal  caries  of  Pott's 
clixeaf<e.  Thus  many  cases  have  been  recorded  where  a  commencing 
Pott's  disease  has  been  mistaken  or  treated  for  "  belly  ache,"  or  for 
trouble  in  the  kidneys  or  bladder  when  the  lower  nerves  are  involved. 
The  position  of  the  spinal  segment  affected  by  disease  or  injury  may 
be  localized  by  the  nerve  or  nerves  involved. 

The  loicer  thoracic  nerves,  besides  furnishing  the  motor  and  sensory 
nerve  supply  to  the  abdomen,  also  supply  the  intercostal  muscles  and 
costal  pleurse.  This  accounts  for  the  fact  that  the  pain  of  a  pleurisy 
near  the  base  of  the  lung  is  often  referred  to  the  stomach  by  chil- 
dren, who  seem  to  have  less  ability  to  locate  pain  than  adults.  The 
abdominal  muscles  are  concerned  with  the  intercostal  muscles  in  the 
movements  of  respiration.  The  association  of  the  sensory  nerves  of 
the  abdomen  with  the  motor  nerves  of  the  inspiratory  muscles  is  illus- 
trated by  the  violent  inspiration  or  deep  gasp  given  when  cold  water 
is  thrown  upon  the  belly.  The  lower  ribs  are  fixed  by  the  reflex  con- 
traction of  the  abdominal  muscles  so  that  this  inspiration  is  confined  to 
the  upper  ribs. 

On  account  of  the  association  in  the  same  nerve  of  the  sensory  and 
motor  fibers,  the  reflex  contraction  of  the  abdominal  muscles  occurs 
more  rapidly  than  if  these  fibers  were  in  separate  nerves.  The  sen- 
sory nerves  are  thus  enabled  to  do  the  duty  of  a  sentinel,  to  give  warn- 
ing that  can  be  immediately  acted  upon  by  the  motor  nerves  by  con- 
tracting the  muscles.  This  is  an  important  provision  for,  as  mt  have 
already  seen,  the  viscera  are  well  protected  from  contusions  only  when 
the  muscles  are  first  contracted.  The  rapidity  of  the  reflex  contrac- 
tion is  well  seen  when  a  cold  hand  is  laid  upon  the  abdomen.  Rigiditv 
of  the  abdominal  muscles  is  immediately  caused  so  that  satisfactory 
abdominal  palpation  cannot  be  practised  unless  the  hands  be  warm. 

A  surface  lesion  like  a  burn,  when  rendered  painful  by  exposure 
to  the  air,  causes  the  abdominal  walls  to  become  rigid.  Not  only 
painful  surface  lesions  but  also  painful  visceral  or  deep  lesions,  like 
peritonitis,  cause  by  reflex  action  a  constant  rigidity  of  the  muscles  so 
as  to  afford  complete  rest  to  the  inflamed  surfaces.  The  patient  with 
peritonitis  may  also  be  unable  to  tolerate  the  least  pressure,  even  of 
the  bed  clothes,  such  is  the  reflex  sensitiveness  of  the  skin. 

The  explanation  of  this  reflex  lies  in  the  connection  of  the  lower 
thoracic  nerves,  which  supply  the  abdominal  parietes,  with  the  splanch- 
nic   nerves   through    the    corresponding   sympathetic   ganglia.      The 


252  THE  ABDOMEN. 

splanchnic  nerves  in  turn  go  to  the  solar  and  other  associated  plexuses 
which  provide  the  nerve  supply  of  the  abdominal  viscera. 

Congenital  Defects  of  the  Abdomen. — During  foetal  life  the  lat- 
eral abdominal  walls  grow  and  bend  inward  to  meet  and  unite  in  the 
median  line,  which  they  do  last  of  all  at  the  umbilicus.  In  so- 
called  extroversion  (or  extrophy)  of  the  bladder  this  median  union  has 
failed  in  the  lower  part,  where  the  base  and  posterior  wall  of  the 
bladder,  whose  front  wall  is  wanting,  is  thrust  forward  by  the  viscera 
beneath  so  as  to  appear  at  or  in  front  of  the  level  of  the  skin 
as  a  red  area  of  mucous  membrane,  moistened  by  urine  trickling 
from  the  visible  opening  of  the  ureters.  This  condition  is  usually 
associated  with  absence  of  the  symphysis  pubis  and  with  epispadias. 

Again,  a  failure  of  the  parietes  to  unite  mesially  may  result  in  a 
protrusion  of  the  viscera,  especially  near  the  umbilicus,  varying  in  size 
from  a  small  hernia  to  one  involving  all  the  movable  viscera.  I  have 
also  seen  a  congenital  separation  of  the  recti  muscles  in  a  child  (see 
p.  245). 

Injuries  and  Wounds  of  the  Abdominal  Wall. — In  contusions  the 
fact  should  be  remembered  that  ecchyiiwsis  may  not  occur  even  though 
the  contusion  be  severe,  and  that  when  the  muscles  are  contracted  the 
viscera  are  likely  to  escape  injury.  A  blow  on  the  abdomen  should 
never  be  considered  trivial  and  refused  treatment  until  after  sufficient 
time  has  elapsed  without  symptoms  to  exclude  the  possibility  of  vis- 
ceral injury.  A  bloir  on  tJie  epigastrium  may  be  followed  by  sudden 
death  without  causing  marks  of  parietal  or  visceral  injury.  The  fatal 
result  is  probably  due  to  an  inhibitory  action  on  the  heart  from  a  con- 
cussion of  the  solar  plexus. 

The  important  distinction  in  wounds  of  the  abdomen  is  between  pene- 
trating and  non-penetrating  grounds.  In  the  former  the  peritoneum  is 
wounded  and  their  seriousness  depends  upon  infection,  either  from 
without  or  from  a  visceral  wound,  and  upon  hemorrhage.  The  sub- 
jacent viscera  may  escape  injury  because  the  weapon  does  not  reach 
them  or,  in  rare  instances,  the  intestines  may  escape  injury  from  a 
bullet  or  a  weapon  thrust  among  them. 

If  infection  of  an  abdominal  wound  occurs,  the  loose  connective 
tissue  between  the  several  layers  and  the  space  between  the  rectus  and 
the  rear  wall  of  its  sheath  favor  the  spread  of  inflammation  and  of 
pus.  The  number  of  layers  and  the  loose  tissue  between  many  of 
them  makes  it  very  easy,  in  probing  a  bullet  or  stab  wound,  for  the 
probe  to  leave  the  track  of  the  wound  and  pass  between  the 
layers  of  muscles  or  fasciae.  Hence  probing  such  wounds  is  to  be 
condemned. 

On  account  of  the  different  direction  of  the  fibers  of  the  several 
muscle  layers  their  retraction  in  a  wound  or  incision  varies,  so  that  an 
irregular  wound  results.  Th€  contraction  of  the  muscles  may  favor 
the  protrusion  of  the  viscera  through  such  a  wound  and,  in  replacing 
them,  care  should  be  taken  not  to  push  them  into  the  spaces  between 
the  muscles  or  beneath  the  peritoneum.     It  is  important  and  some- 


OPERATIONS  AND  INCISIONS.  253 

times  difficult  to  apply  the  sutures  so  that  the  cut  edges  of  each  of  the 
muscular  layers  are  in  apposition,  and  unless  this  is  done  the  strength 
of  the  wall  is  impaired.  It  is  also  of  the  utmost  importance  that  the 
peritoneum  on  the  two  sides  of  the  wound  should  be  sutured  so  as  to 
bring  about  its  speedy  union,  otherwise  a  gap  is  left  on  its  surface,  which 
favors  the  formation  of  hernia  at  the  site  of  the  wound.  The  constant 
movement  of  the  abdominal  wall  does  not  allow  that  rest  which  is  so 
favorable  or  even  essential  to  wound  healing,  but  in  spite  of  this  most 
wounds  heal  well  here. 

Operations  and  Incisions. 

Operations  are  practised  upon  all  the  abdominal  viscera,  and  for 
exploration  or  diagnosis.  The  position  of  the  incision  varies  with  the 
viscus  to  be  approached.  The  general  rule  that  the  incision  should 
give  free  access  and  avoid  wounding  nerves  and  large  or  important 
vessels  is  to  be  followed,  but  in  addition  the  danger  of  suhsequent 
hernia  is  to  be  considered.  This  danger  is  greater  in  the  lower  part  of 
the  abdomen,  for  here  gravity  adds  to  the  protruding  force  of  the 
intra-abdominal  pressure,  due  to  muscular  action.  Also,  as  Hyrtl 
says,  aponeurosis  is  less  resistant  than  muscle  and  a  scar  in  the 
former  is  more  likely  to  yield  than  one  in  the  latter. 

Incisions  may  be  directed  vertically,  horizontally,  or  obliquely. 
Vertical  incisions  are  most  commonly  practiced  along  the  two  fibrous 
or  aponeurotic  lines,  the  linea  alba  and  the  linea  semilunaris.  Through 
the  latter  line  we  may  expose  the  appendix  vermiformis,  the  kidney, 
the  gall-bladder  and  the  bile-ducts ;  but  the  incision  is  objectionable 
because  it  divides  nerves  that  supply  a  part  of  the  rectus  muscle,  and 
the  scar  is  in  relatively  thin  fibrous  tissue  and  is  liable  to  yield  and  be 
followed  by  hernia. 

Of  course,  in  some  cases,  other  considerations  (greater  safety,  etc.) 
may  outweigh  the  objections.  The  danger  of  hernia  may  be  obviated 
by  incising  the  sheath  of  the  rectus  muscle  1-2  cm.  internal  to  its  outer 
border,  retracting  the  muscle  inward  and  dividing  the  deep  layer  of 
the  sheath  in  line  with  the  incision  of  the  superficial  layer,  thus 
forming  a  trap-door  incision.  In  the  upper  part  of  the  linea  semilunaris 
the  incision  is  not  through  fibrous  tissue  only,  but  we  meet  with  the 
transverse  fibers  of  the  transversalis  muscle,  which  here  passes  behind 
the  rectus. 

Of  all  incisions  that  in  or  near  the  linea  a/ha  is  the  most  common. 
It  is  practised  in  most  operations  on  the  pelvic  viscera,  in  most 
exploratory  operations  and  in  many  others.  The  following  advan- 
tages are  claimed  for  incisions  through  the  linea  alba:  (1)  Slight 
vascularity ;  (2)  few  important  structures  to  be  divided ;  (3)  accei^si- 
hility  to  all  parts. 

1.  The  .sY/r////  vascularitji  is  a  disadra)dage,  for  it  delays  rapid  and 
firm  healing  and  so  predisposes  to  hernia. 

2.  Hei'nia  is  also  favored  hi/  the  comparatively  thin  scar  resulting 


254  THE  ABDOMEN. 

from  the  few  blended  structures  to  be  divided,  which  also  renders  the 
incision  more  difficult,  as  it  is  hard  to  tell  its  exact  depth  at  any  given 
stage  for  want  of  landmarks.  Moreover,  if  we  have  to  extend  the 
median  incision  past  the  umbilicus  we  encircle  it,  usually  on  the  left 
because  of  the  danger  of  wounding  the  parumbilical  vein,  sometimes 
of  large  size,  which  passes  along  the  round  ligament  of  the  liver  to 
the  right  of  the  median  line.  But  as  it  is  difficult  to  render  the  um- 
bilicus aseptic  there  is  danger  of  infecting  the  incision  or  the  track  of 
the  sutures  which  unite  this  part  of  the  incision.  The  above  dis- 
advantages of  incisions  in  the  linea  alba  are  avoided  and  the  advan- 
tages shared  by  an  incision  through  the  rectus  muscle  about  an  inch 
from  the  median  line,  separating  bluntly  the  fibers  of  the  muscle  or 
retracting  it  outward  in  the  manner  of  a  trap-door.  The  linese  trans- 
versse  offer  no  serious  obstacle  to  the  vertical  separation  of  the  fibers 
of  the  rectus  muscle. 

In  the  epigastrium  the  stomach  is  irell  exposed  by  a  vertical  incision, 
which  may  be  median  or  through  the  inner  half  of  the  rectus  muscle, 
or  by  an  oblique,  a  transverse,  or  an  angular  incision. 

Transverse  or  somewhat  oblique  incisions  in  the  rectus  above  the  um- 
bilicus are  not  objectionable,  if  properly  united,  for  they  only  increase 
the  number  of  linese  trans versae  and  are  not  likely  to  wound  the 
nerves.  Below  the  umbilicus  we  should  bear  in  mind  the  position  of 
the  deep  epigastric  artery  in  transverse  section  of  the  rectus. 

The  transverse  incision  just  above  the  pubes  to  expose  the  bladder  ap- 
pears to  me  to  offer  little  or  no  advantage  over  the  vertical  and,  un- 
less properly  healed,  it  is  likely  to  impair  the  function  of  the  muscle 
as  well  as  to  lead  to  ventral  hernia. 

In  the  area  outside  of  the  linece  semilunares  the  best  incisions  are  those 
directed  obliquely  or  transversely,  parallel,  or  nearly  parallel,  with 
the  cleavage  lines  of  the  skin  and  the  direction  of  the  nerves.  Here 
the  incisions  are  through  a  thicker  muscular  wall  which,  if  properly 
united,  affords  more  protection  against  hernia  than  those  through 
thinner  aponeurotic  structures. 

In  the  lower  half  of  this  area  we  commonly  incise  parallel  to  the 
fibers  of  the  external  oblique  and  its  aponeurosis,  /.  (•.,  at  right  angles 
to  a  line  joining  the  anterior  superior  iliac  spine  and  the  umbilicus. 
Separating  the  external  oblique  fibers  we  may  reach  the  transversalis 
fascia  by  blunt  separation  of  the  internal  oblique  and  transversalis 
muscles,  which  are  practically  in  the  same  line.  As  this  separation  of 
the  muscular  layers  is  along  different  lines,  according  to  the  direction 
of  their  fibers,  we  do  not  get  as  much  room  from  a  given  length  of  skin 
incision  as  if  we  incised  the  deeper  muscles.  The  incision  of  the 
latter  may  be  advisable  if  much  room  is  needed  ;  but  the  blunt  inter- 
muscular incision  is  an  almost  absolute  safeguard  against  hernia,  as  the 
muscles  come  naturally  together  and  close  the  wound  when  we  cease 
to  retract  them.  Moreover  we  can  readily  enlarge  the  intermuscular 
incision  by  incising  the  sheath  of  the  rectus  toward  the  median  line 
and  retracting  the  muscle  in  the  same  direction. 


THE  REGIOXS  OF  THE  ABDOMEN.  255 

In  the  upper  part  of  this  area,  an  oblique  incision  nearly  parallel 
with  the  costal  margin  is  nearly  in  line  Mith  the  nerves  and  cleavage 
lines  of  the  skin,  and  gives  a  good  exposure  of  the  parts  about  the 
liver  on  the  right  side,  the  stomach  or  spleen  on  the  left  side. 

To  expose  the  liver,  gall-bladder,  etc.,  an  oblique  incision  from  a 
point  below  and  external  to  the  ensiform  cartilage,  one  half  inch  or 
more  to  the  inner  side  of  the  costal  margin,  to  a  point  half  an  inch 
above  the  tip  of  the  eleventh  rib  will  only  divide  the  ninth  thoracic 
nerve.  The  same  is  true  of  a  vertical  incision  through  the  outer  part 
of  the  rectus  muscle  from  a  point  half  an  inch  below  the  lower  border 
of  the  eighth  costal  cartilage  to  a  point  tAvo  inches  above  the  umbilicus. 
For  the  same  purpose  Bevan's  incision  is  serviceable,  consisting  of  a 
vertical  incision,  along  the  outer  border  of  the  right  rectus,  whose  lower 
end  may  be  prolonged  obliquely  outward,  near  the  level  of  the  um- 
bilicus, and  whose  upper  end,  three  fourths  inch  below  the  costal 
margin,  may  be  prolonged  obliquely  inward  and  upward  by  incising 
the  sheath  of  the  rectus  and  retracting  the  muscle.  When  much  room 
is  required  for  the  safety  of  an  operation  the  incision  must  be  enlarged 
or  added  to  where  and  in  what  way  it  is  necessary,  but  in  general  the 
above  considerations  should  apply. 

The  Regions  of  the  Abdomen. 

The  abdomen  has  been  arbifrartii/  (Uruhd  into  nine  regions,  so  that 
the  viscera  of  these  regions  may  be  localized  with  reference  to  the  sur- 
face area  of  these  regions.  Of  course  the  relation  of  the  viscera  to 
the  overlying  surface  is  only  approximate,  for  the  position  of  the 
viscera  has  a  wide  range  of  physiological  variation  in  different  sub- 
jects or  in  the  same  subject  at  different  times.  This  regional  division 
may  be  of  service  in  medical  education,  but  in  practice  we  determine 
the  position  of  viscera  by  palpation,  etc.,  and  by  reference  to  well- 
defined  landmarks. 

To  aid  the  more  precise  description  of  the  position  of  pathological 
or  medicolegal  findings  the  regions  may  be  of  more  service.  Unfor- 
tunately there  is  confusion  and  variation  instead  of  uniformity  in  the 
boundaries  of  these  nine  regions. 

The  two  vertical  and  the  two  horizontal  planes  which  mark  off  these 
regions  must  be  fixed  with  reference  to  landmarks  easily  located  on  the 
living  body. 

As  usually  described,  the  vertical  planes  pasx  through  the  middle  of 
the  inguinal  (Poupart's)  ligament,  and  nearly  correspond  with  the  linete 
semilunares  in  the  two  upper  zones.  Hence  they  differ  but  little  from 
the  planes  proposed  along  the  outer  border  of  the  recti, ^  except 
in  the  lower  zone,  where  the  latter  make  the  inguinal  canal  in  the  lat- 
eral regions,  the  former  in  the  median  region.  The  planes  drawn 
vertical  to  the  iliopectineal  eminences"  are  objectionable  because  these 

^Morris'  Anatomy,  2d  edition,  1898. 
*  Joessel  ;  Gray,  American  edition. 


256 


THE  ABDOMEN. 


eminences  cannot  be  easily  enough  located  from  the  surface  to  serve  as 
starting  points. 

The  upper  horizontal  plane  is  best  drawn  as  a  subcostal  plane  con- 
necting the  lowest  points  of  the  tenth  costal  cartilages  of  each  side. 
The  ninth  or  eighth  costal  cartilages  have  been  used  by  some,  or  the 
point  where  the  vertical  planes  meet  the  costal  margin. 

The  lower  horizontal  plane,  as  usually  given,  passes  through  the  two 
anterior  superior  ili((c  spines.  Some  describe  it  as  between  the  highest 
point  of  the  iliac  crests,  others  11  inches  lower,  through  the  point  of 
the  iliac  crests  most  prominent  laterally,  or  the  tuberculum  cristse. 

It  is  as  important  to  know  the  viscera  which  are  cut  by  these  planes 
as  the  viscera  in  the  areas  bounded  by  them. 

The  vertical  planes  cut  from  below  upward  on  the  rigid  side,  the  apex 
of  the  cfecum,  small  intestine,  transverse  colon,  kidney,  and  gall-blad- 
der (often);  and  on  the  left  side,  the  sigmoid  flexure,  small  intestine, 
kidney,  transverse  colon,  pancreas,  stomach,  and  spleen. 

The  upper  horizontal  plane  passes  through  the  second  (or  third)  lum- 
bar vertebra  behind,  and  runs  two  inches  above  the  umbilicus  in  front. 
The  viscera  cut  by  it  are  the  stomach,  transverse,  ascending  and 
descending  colons,  duodenum  (lower  curve),  both  kidneys  and  the 
small  intestine. 

The  lower  horizontcd  [Jane  (interspinous)  passes  at  about  the  level 
of  the  top  of  the  sacral  promontory  and  cuts  the  cfecum,  small  intestine 
and  sigmoid  flexure.  The  names  and  visceral  contents  of  the  nine 
regions  marked  off  by  the  above  planes  may  be  seen  in  the  following 
table.  The  adjacent  parts  of  the  lower  iliac  and  hypogastric  regions 
form  the  inguinal  region. 


Right. 
R.  Hypochondriac. 

Liver,  greater  part  of 
right  lobe.  Gall-blad- 
der, part  of  fundus 
(sometimes).  Kidney, 
upper  and  outer  part. 
Colon,  hepatic  flexure 
and  part  of  ascending 
colon. 


Middle. 

Epigastric. 

Liver,  whole  or 
greater  part  of  left 
lobe,  part  of  right 
lobe.  Most  or  all  of 
gall-b la dder.  Stomach , 
middle  and  pyloric 
regions,  both  orifices. 
Lntestines  ;  duodenum, 
first  and  second  por- 
tions and  end  of  third 
portion.  Small  intes- 
tine. Transverse  colon 
(part  of).  Pancreas, 
head  and  body ;  Spleen, 
upper  and  inner  part. 
Kidneys,  upper  and 
inner  part.     Adrenals. 


Left. 
L.  Hypochondriac. 

Xhy'?',  sometimes  part 
of  left  lobe  ;  Stomach, 
fundus;  AS/)^een, greater 
part ;  Pancreas,  tail ; 
Kidney,  upper  and 
outer  part ;  Colon, 
splenic  flexure,  and  part 
of  descending  colon. 


THE   UMBILICUS  AND    UMBILICAL  HERNIA. 


257 


Horizontal  Plane  at  Level  of  Lowest  Point  of  the  Tenth  Costal  Cartilages. 
Right  Lumbar.  Umbilical.  Left  Lumbar. 


ICidney,  lower  and 
outer  part ;  Intestine  ; 
ascending  colon;  caeum 
(part  of) ;  vermiform 
appendix  (often) ;  part 
of  ileum  and  its  termi- 
nation. 


Kidneys,  lower  and 
inner  portion  with  ure- 
ters ;  Intestine,  third 
part  duodenum  ;  part 
of  Jfjununi  and  ileum; 
greater  part  of  trans- 
verse colon ;  part  of 
sigmoid  Jlexure. 


Kidney,  lower  and 
outer  part  ;  Intestine, 
jejunum;  part  of  des- 
cending colon  ;  part  of 
sigmoid  Jlexure. 


Horizontal  Plane  at  Level  of  Anterior  Superior  Iliac  -Opines. 
Right  Iliac.  Hypogastric.  Left  Iliac. 

Intestine;  ileum,  part        Intestine,  small  Intes-        Intestine;  small  In- 
of.    Qecwm,  lower  part     fine.i ;  part  of  sigmoid    testine ;  pa.Tt  of  sigmoid 
of.     Vermiform  a ppen-    Jlexure;   upper  part  of   flexure, 
dix.  rectum;  tip  of  caecum, 

usually;  vermiform  ap- 
pendix (often).  Blad- 
der in  children  and, 
when  distended,  in 
adults.  Vterus,  fun- 
dus and  appendages. 

The  Umbilicus  and  Umbilical  Hernia. 

In  eaT\y  foetal  life  there  pass  through  the  umbilical  opening,  which  is 
bordered  by  fibers  of  the  linea  alba,  the  urachus,  the  umbilical  arteries 
and  vein  and  a  loop  of  small  intestine.  Outside  of  the  body  these  are 
bound  together  by  embryonic  tissue  (Wharton's  jelly)  and  covered 
with  amnion  to  form  the  umbilical  cord.  Later  the  inte.^tinal  loop  re- 
tract within  the  abdomen,  leaving  in  the  cord,  for  a  time,  the  vitello- 
intestinal  dud  which  connects  the  end  of  the  loop  with  the  yolk  sac. 
The  proximal  end  of  this  duct  may  persist  as  a  finger-like  process, 
Meckel's  diverticulum,  connected  with  the  lower  end  of  the  ileum,  from 
one  to  three  feet  from  the  ileocecal  valve. 

Occasionally,  from  imperfect  development,  the  foetal  condition  per- 
sists at  birth,  and  a  loop  of  intestine  or  an  intestinal  diverticulum  pro- 
jects a  varial)le  distance  through  the  umbilical  ring  into  the  cord. 
This  constitutes  a  congenital  umbilical  hernia.  If  care  is  not  exercised 
in  tying  the  cord  this  projection  may  be  tied  or  cut  off  causing  afvcal 
fistula,  which  may  be  preceded  liy  ol)struction  if  an  intestinal  loop  is 
tied.  Two  or  more  ca.ses  of  such  an  accident  are  on  record.  ^lore 
rarely  the  hernial  protrusion  is  larger  and  contains  a  larger  mass  of 
intestine  or  other  viscera  witii  a  thin  covering. 

At  birth  the  ford  /.s  tied  a  short  distance  from  the  belly  wall  and 
17 


258  THE  ABDOMEN. 

the  proximal  end  shrivels,  dries  up  and  in  about  five  days  drops  of  at 
the  same  spot  in  all  cases,  i.  e.,  the  level  of  the  abdomen,  no  matter 
where  the  ligature  is  applied.  This  is  accounted  for  by  the  sphincter- 
like arrangement  of  elastic  fibers  around  the  umbilicus  (especially  on 
its  deep  aspect),  which  contract  and  shut  off  like  a  ligature  the  vessels 
passing  through  the  ring,  including  those  supplying  the  cord  itself. 

At  birth  and  for  some  time  afterward  a  dixtinct  ring  can  he  felt  at  the 
iimbilieus.  At  the  spot  where  the  stump  of  the  cord  separates  from 
the  belly  wall  a  scar  forms  which  binds  together  the  stum|)s  of  the 
umbilical  vessels.  The  skin  rapidly  grows  over  this  scar  which,  when 
it  contracts,  throws  the  skin  into  folds  forming  the  umbilical  papilla. 
It  is  on  account  of  the  creases  between  the  folds  that  it  is  so  difficult 
to  make  the  umbilicus  aseptic  before  operation. 

As  we  look  at  this  scar  from  behind  we  see  the  converging  empty 
umbilical  arteries  and  the  median  urachus  running  to  it  from  below, 
and  the  empty  umbilical  vein  running  upward  from  it.  At  first  there 
is  a  slight  depression  in  the  center  of  the  contracting  ring,  into  which 
there  is  a  little  projection  of  peritoneum.  During  infancy  a  hernia 
may  protrude  through  the  not  yet  firm  cicatrix  in  the  still  open  ring, 
between  the  arteries  and  the  vein,  or  at  a  later  period  above  them. 
This  is  known  as  infantile  umbilical  hernia.  It  occurs  in  the  first  few 
months  of  infancy  and  is  due  to  frequent  coughing,  crying,  or  strain- 
ing on  account  of  constipation,  phimosis,  etc.  If  joroperly  treated  by 
being  kept  reduced  it  usually  heals  without  operation,  for  the  cicatri- 
cial contraction  of  the  ring  can  then  go  on  to  final  closure. 

The  umbilical  vessels  having  become  obliterated  and  reduced  to 
fil)rous  cords  in  the  first  month  of  infant  life,  the  abdomen  grows  more 
rapidly  than  these  obliterated  vessels,  which  therefore  pull  upon  the 
umbilical  cicatrix.  The  traction  of  the  two  obliterated  arteries  and 
the  urachus  is  stronger  than  that  of  the  vein,  so  that  the  fibrous  cords 
representing  all  three  vessels  are  pulled  down  to  the  lower  margin  of 
the  umbilicus.  The  upper  half  of  the  scar  is  thin  while  the  vessel 
cicatrix,  in  the  lower  half,  becomes  the  strongest  part  of  the  umbilicus 
and  the  latter  the  strongest  point  in  the  abdominal  wall.  Conse- 
quently in  adult  life  an  acquired  umbilical  hernia  either  protrudes 
through  the  upper  part  of  the  reopened  ring  or  altogether  above  it, 
and  is  in  reality  a  hernia  of  the  linea  alba,  on  the  lower  aspect  of 
which  appears  the  umbilical  cicatrix. 

On  the  deep  aspect  of  the  umbilicus  in  about  two  thirds  of  the  cases 
examined,'  are  seen  transverse  fibers  passing  from  the  inner  border  of 
one  rectus  sheath  to  that  of  the  other.  They  are  known  as  the_f«.sc/« 
umbilicalis,  are  adherent  to  the  peritoneum,  cover  the  deep  surface  of 
the  umbilical  vein  and  represent  a  thickening  of  the  transversalis 
fascia.  In  certain  cases  it  is  present  only  above  and  below  the  um- 
bilicus, leaving  the  latter  free  and  theoretically  more  exposed  to 
hernia.  But  as  acquired  hernia  occurs  uniformly  above  the  umbili- 
cus the  common  arrangement,  where  the  fascia  ends  by  a  free  margin 
1  Sachs  (Virch.  Arch.,  IVl.  107). 


COVERINGS  OF   UMBILICAL  IIERNIJE.  259 

a  little  above  the  cicatrix,  may   he  equally  favorable  to  hernia   for- 
mation. 

Richet^  likened  a  canal-like  space  above  the  umbilicus,  between 
the  linea  alba  and  this  fascia,  to  the  inguinal  canal  in  relation  to  hernia 
formation.     But  the  analogy  is  purely  an  imaginary  one. 

The  umhi/lrdl  jxipilhi,  or  cutaneous  cicatrix  proper,  is  at  the  bottom 
of  a  dej)ression  which  is  due  to  a  lack  of  subcutaneous  fat  immediately 
about  it.  It  corresponds  to  the  original  fibrous  ring  of  the  umbilicus, 
derived  from  the  tissues  of  the  linea  alba.  The  layers  of  the  abdo- 
men in  this  cicatricial  area,  /.  e.,  skin,  aponeurotic  scar  tissue,  fascia 
transversalis  and  peritoneum,  are  so  thin  and  closely  adherent  that, 
when  stretched  out  by  a  hernia,  we  can  hardly  avoid  opening  the  peri- 
toneal sac,  unless  by  incising  well  above,  below,  or  laterally.  The 
superficial  fascia  is  practically  wanting. 

In  congenital  and  many  infantile  hernia  the  omentum  is  not  found 
in  the  sac,  for  at  this  jieriod  it  has  not  developed  as  low  as  this.  In 
the  acquired  form  it  is  nearly  always  present  and  adherent. 

Coverings  of  Umbilical  Hemiae. — Congenital  hemise,  embryonic 
tissue  of  the  cord  and  an  anniiotic  layer  continuous  with  the  skin  at 
the  ring.     There  is  no  true  sac. 

Infantile  hemise,  peritoneum,  forming  the  sac,  transversalis  fascia, 
skin.     (The  superficial  fascia  is  so  scanty  as  to  be  practically  wanting.) 

Acquired  hernise,  the  same  as  the  infantile  variety  with  the  addition 
of  the  superficial  fascia  and  the  aponeurotic  tissue  of  the  linea  alba, 
for  the  hernia  is  really  through  the  linea  alba  above  the  scar. 

The  subperitoneal  tissue  is  so  small  iu  amount  as  to  be  omitted,  for 
the  peritoneum  is  here  very  adherent  to  the  fascia. 

In  fcetal  life  the  urachus,  derived  like  the  bladder  from  the  stalk  of 
the  allantois,  has  a  lumen  connected  with  that  of  the  bladder,  etc. 
According  to  Luschka,  a  total  obliteration  of  the  lumen  of  the  urachus 
is  not  the  rule,  but  an  unobliterated  part  is  usually  found.  This  may 
be  connected  with  the  bladder  or  shut  off  from  it.  Occasionally  such 
a  patent  portion  opens  as  ajistul((  at  the  umhilicus.  A  probe  passes  a 
variable  distance  down  the  urachus  and  a  sero-mucous  secretion,  not 
urine,  is  discharged  from  the  opening  of  the  fistula.  I  have  met  with 
a  few  such  cases,  which  are  readily  closed  by  scraping  and  cauteri- 
zation. 

A  few  cases  are  on  record  where  the  f(otal  canal  of  the  urachus  has 
remained  open  from  the  bladder  to  the  umbilicus,  so  that  on  micturi- 
tion the  urine  would  stream  from  the  latter  when  its  passage  through 
the  urethra  was  impeded.  In  case  of  stricture  of  the  urethra  its  func- 
tion could  be  performed  by  such  a  urachus. 

Another  abnormal  condition  observed  is  a  reopeniuff  of  the  urachus 
during  retention  of  urine,  thus  allowing  urine  to  escape  at  the  navel 
and  relieve  the  retention.  But,  as  Hyrtl  suggests,  it  is  not  unlikely 
that  in  such  a  case  the  urachus  was  patent  as  far  as  the  umbilicus. 
Urinary  calculi  have  also  been  found  //(  the  urachus,  where  the  latter 
'  Anat.  (liinirgicalc,  5th  ed.,  p.  74o. 


260  THE  ABDOMEN. 

connected  with  the  bladder,  and  in  one  case  a  stone  Avas  removed  from 
the  bladder  bv  the  aid  of  a  finger  passed  through  a  patent  urachus. 

The  Inguinal  Region  and  Inguinal  Hernia. 

The  boundaries  of  this  region  are  Poupart's  ligament  below,  a  hori- 
zontal line  from  the  anterior  superior  iliac  spine  above,  and  internally 
the  median  line  or,  for  practical  purposes,  the  outer  border  of  the 
rectus  muscle.  The  several  layers  of  the  belly  wall  are  essentially 
the  same  here  as  elsewhere  anteriorly,  except  that  (1)  the  intercolummar 
fibers  and  fascia  are  closely  joined  to  the  outer  surface  of  the  exterj^al 
oblique  aponeurosis  and  (2)  the  conjoined  tendon,  representing  the 
internal  oljlique  and  transversalis  muscles,  arches  over  from  the  outer 
half  of  Poupart's  ligament  to  the  iliopectiueal  line  and  the  pubic  crest. 
This  leaves  bare  of  these  muscles  the  inner  half  of  the  ligament  and 
a  narrow  semilunar  space  above  it,  corresponding  to  the  inner  two 
thirds  of  the  inguinal  canal. 

Superficial  inguinal  lymphatic  nodes,  eight  to  ten  in  number,  are  found 
between  the  superficial  and  deep  layers  of  the  superficial  fascia  in  two 
sets,  an  oblique  set  along  and  just  above  Poupart's  ligament,  and  a 
vertical  set  over  and  about  the  saphenous  opening.  The  internal  group 
of  the  oblique  or  inguinal  set  receives  the  lymphatics  from  the  external 
genitals,  distal  part  of  the  urethra,  perineum,  and  the  inner  part  of 
the  buttock  ;  the  middle  groxip  those  from  the  abdominal  parietes  below 
the  umljilicus,  the  external  group  those  from  the  outer  part  of  the  but- 
tock and  the  lower  part  of  the  back.  These  become  enlarged  from 
cancerous,  syphilitic  and  suppurative  affections  of  these  regions,  and 
we  can  often  tell  the  part  atfected  by  the  nodes  first  involved. 

Their  efferent  vessels  pass  through  the  cribriform  or  the  deep  fascia 
to  reach  the  deep  inguinal  or  the  external  iliac  nodes.  The  commonest 
cause  of  enlargement  of  these  nodes  is  venereal  disease,  but  enlarge- 
ment may  occur  here  without  visible  local  lesion,  as  with  the  cervical 
lymph  nodes. 

AVhat  gives  this  region  its  importance  is  the  presence  of  the  inguinal 
canal,  an  oblique  passageway  through  the  abdominal  wall  for  the  sper- 
matic cord  in  the  male  and  the  round  ligament  in  the  female.  This 
canal,  like  many  others  in  the  body,  is  not  an  actual  hut  a  potential  canal , 
a  breach  or  track  forming  a  iceak  spot  in  the  abdominal  wall  along  which 
a  body  may  be  thrust.  An  open  canal  is  a  pathological  condition  due 
to  hernia. 

The  inguinal  canal  in  the  male  is  formed  by  the  passage  of  the 
processus  vaginalis  and  the  testis  through  the  abdominal  wall,  which 
then  closes  down  snugly  on  the  spermatic  cord,  which  follows  the  testis. 

It  should  be  remembered  that  the  ffW/.s,  etc.,  does  not  break  through 
each  layer  as  a  bullet  through  a  board,  but  puslies  before  it  tJte  several 
layers  which  are  stretched  out  to  form  a  laminated  covering  of  the 
testis  and  cord. 

The  peritoneum  forms  an  exception  to  the  statement  that  the  layers 
of  the  abdominal  parietes  are  pushed  before  the  testes,  etc.     The  peri- 


THE  EXTERNAL  ABDOMINAL  RING.  2G1 

toneum  is  the  first  structure  to  pass  out  througii  the  inguinal  canal  as 
the  processus  vaginalis.  Tiie  testis  is  from  the  outset  outside  of  the 
peritoneum,  having  clevelo})ed  behind  it,  so  that  it  need  not  and  can- 
not push  it  as  a  pouch  before  it,  but  descends  alongside  of  and  outside 
of  the  processus  vaginalis  through  the  inguinal  canal  and  so  into  the 
scrotum.     (See  scrotum  and  testes.) 

The  two  ends  or  ojienings  of  the  canal  are  called  the  (ihdoiainal  rings. 
The  inferior  and  mesial  one  is  known  as  the  external  ring  because  it  is 
superficial,  though  more  internal  or  mesial  than  the  internal  ring. 

The  external  or  superficial  abdominal  ring  is  where  the  cord, 
or  round  ligament,  passes  through  the  aponeurosis  of  the  external  ob- 
lique and  spreads  apart  two  fasciculi  of  this  aponeurosis  called  pillars 
of  the  ring.  A  triangular  gap  is  thus  formed  with  its  base  downward 
and  inward  over  the  spine  and  outer  part  of  the  crest  of  the  os  pubis. 
The  lower  and  outer  fasciculus  or  "  pillar  "  of  the  ring  blends  with  and 
in  fact  is  the  inguinal  (Poupart's)  ligament.  It  is  attached  to  the 
pubic  spine  internally  and  the  fascia  lata  below.  It  is  the  stronger 
and  more  posterior  pillar,  and  on  it  rests  the  cord  or  round  ligament. 
Tile  upper  and  inner  '' pillar"  is  attached  to  the  pubic  crest.  So- 
called  intercolumnar  fibers,  passing  upwards  and  inwards  from  the  outer 
half  of  Poupart's  ligament,  bridge  across  the  outer  angle  where  the 
two  pillars  meet,  round  off  this  angle  and  bind  securely  together  the 
fibers  of  the  two  pillars  so  as  to  prevent  their  further  separation.  These 
intercolumnar  fibers  are  joined  together  by  a  thin  membrane  into  a 
fascia,  the  intercolumnar  fccscia,  which  is  attached  to  the  margins  of  the 
pillars,  and  is  prolonged  over  the  cord  and  testes  as  the  external  sper- 
matic fascia.  It  represents  the  covering  furnished  by  the  external 
oblique  aponeurosis. 

The  base  of  the  triangular  gap  is  rounded  off  by  the  triangular  liga- 
ment, lying  at  a  deeper  level  than  the  ring,  and  sometimes  known  as 
the  posterior  pillar.  Thus  the  external  ring  is  oval  with  its  long 
diameter  obliquely  vertical.  It  lies  one  inch  (2—3  cm.)  from  the 
median  line,  above  and  internal  to  the  pubic  spine,  and  can  readily  be 
felt  by  invaginating  the  scrotum  with  the  finger  and  following  up  the 
front  of  the  cord. 

It  averages  one  inch  by  one  half  inch  though  its  size  is  very  variable 
and  it  is  smaller  in  the  female  than  in  the  male.  In  cases  of  non- 
descent  of  the  testis,  or  after  its  removal,  the  external  ring  may  be 
narrowed  or  obliterated.  Normally  it  will  admit  the  tip  of  the  index 
finger.  It  is  felt  to  be  enlarged  in  flexion,  adduction  and  inward  rota- 
tion of  the  thigh  by  means  of  the  relaxation  of  the  fascia  lata  and 
thereby  of  Poupart's  ligament,  the  external  pillar,  which  is  attached  to 
this  fascia.  Hence  the  thigh  is  placed  in  this  position  for  dwis  or  for 
e.ramin((tion  of  the  canal,  also  to  see  if  a  truss  or  bandage  fits  snugly 
enough  to  retain  a  hernia.  Vice  versa  it  is  narrowed  in  extension, 
abduction  and  outward  rotation  of  the  thigh  by  the  traction  of  the 
fascia  lata  making  tense  the  external  oblique  aponeurosis.  This  posi- 
tion is  one  w^hich  may  be  employed  after  operations  for  hernia. 


262  THE  ABDOMEN. 

The  internal  or  deep  abdominal  ring  is  where  the  cord  passes 
through  the  transversalis  fascia,  which  is  here  called  the  infundibuli- 
form  fascia  because  it  has  formed  a  funnel-shaped  pouch  for  the  testis 
and  still  presents  a  slight  pit  or  depression.  The  inner  fascial  margin 
of  this  depression  forms  a  prominent  crescentic  edge,  due  to  the  trac- 
tion of  the  vas  deferens  as  it  bends  inward  and  downward  into  the 
canal. 

This  ring  lies  about  half  an  inch  above  Poupart's  ligament  at  a  point 
slightly  internal  to  its  center.  It  is  oval  in  shape  with  its  long  diam- 
eter directed  vertically.  The  transi^erscdis  fascia,  is  not  brolrti  through 
by  the  passage  of  the  testis  or  the  round  ligament  but  is  carried  down 
with  them  as  an  enveloping  pouch,  the  infundibuliform  or  internal  sper- 
matic fascia,  whose  upper  opening,  the  internal  ring,  is  closed  around 
the  cord  or  round  ligament. 

The  inguinal  canal,  extending  obliquely  between  these  two  rings, 
measures  1^  inches  in  length  in  the  male  and  two  inches  in  the  female. 
Its  direction  is  somewhat  more  vertical  than  Poupart's  ligament,  and  its 
obliquity  serves  as  a  valve  to  lessen  the  chance  of  a  hernia  entering  it. 
Its  size  varies  with  that  of  the  cord  or  round  ligament  which  occupies 
it,  hence  it  is  smaller  in  the  female.  The  right  canal  averages  larger 
than  the  left,  a  fact  that  may  help  to  explain  the  preponderance  of 
hernia  on  the  right  side. 

Walls  of  the  Canal.  (Fig.  65.) — In  front  lie  the  aponeurosis  of 
the  external  oblique  and,  in  the  outer  third,  the  lower  fleshy  fibers  of 
the  conjoined  tendon.  These  same  fibers  arch  above  it.  Behind  lie 
the  transversalis  fiscia  and,  opposite  the  inner  half  of  the  external  ring, 
the  conjoined  tendon  and  the  triangular  ligament.  Above  it  is  the  con- 
joined tendon,  below  is  the  gutter  formed  by  the  junction  of  Poupart's 
ligament  and  the  transversalis  fascia,  above  which  lies  the  cord  at  a 
distance  which  increases,  as  we  proceed  outward,  to  |  inch  at  the 
internal  ring.  This  fact  is  important  in  opening  iliac  abscesses  or 
exposing  the  external  iliac  artery,  in  this  space. 

Fat  is  abundant  in  the  subperitoneal  tissue  behind  the  rear  wall  of 
the  canal,  so  that  masses  of  fat  are  commonly  found  adherent  to  the 
outside  of  the  neck  of  a  hernial  sac,  especially  on  its  mesial  side. 

Lying  in  this  subperitoneal  tissue  are  the  deep  epigastric  vessels, 
structures  of  great  practical  importance,  which  pass  belli nd  the  canal  ]nst 
internal  to  the  internal  ring.  Between  the  internal  ring  and  these  vessels 
the  transversalis  fascia  is  very  strong  ;  internal  to  the  vessels,  where  a 
direct  hernia  makes  its  way  forward,  it  is  much  weaker.  Besides  the 
front  walls  of  the  canal  as  above  given,  other  tissue  layers,  derived 
from  the  layers  of  the  abdominal  wall,  form  the  coverings  of  the  sper- 
matic cord  or  of  a  hernia.  Thus  the  infundibuliform  portion  of  the 
transversalis  fascia  is  prolonged  down  the  canal  as  a  tubular  covering 
of  the  cord,  etc.  As  the  testis  passes  beneath  the  lower  fibers  of  the 
internal  ol)lique,  in  the  conjoined  tendon,  these  fibers  are  pulled  down 
and  spread  out  in  front  and  at  the  sides  of  the  cord  or  a  hernia,  as  the 
cremasteric  muscle  and  fascia.     Occasionally  the  testis  passes  between 


PLATE   XXXI. 


FIG.  65. 


EXT.    OBLIQUE  _!' 
APONEU  ROSIS 
INT.    OBLIQUE  _ 
MUSCLE 


PERITONEUIV 

TBANSVEFSALIS 

FASCIA 
TRANSVERSAUIS 

MUSCLE 


SPERMATIC_l«l' 

CORD     UAA^S*' 


FASCIA    LATA 


sagittal  section  of  anterior  abdominal  wall   through  the 
middle  of  the  inguinal  canal.     (Tillaux.) 


PLATE    XXXII. 


FIG.  Si 


Plica  hypogastrica 


I'Jira  urachl 


^\      Middle 
inguinal  fossa 


Into  nnl  inguinal 
fossa 


I      Siijicrior  vest- 
J         cul  artery 


Posterior  view  of  the  anterior  abdominal  wall  in  its  lower  half. 
The  peritoneum  is  in  place,  and  the  various  cords  are  shining 
through.      (After  Joessel.) 


EXTERNAL   OR  INDIRECT  INGUINAL  HERNIA.  2G3 

instead  of  Ijonouth  these  fibers,  in  wliioh  case  tlie  cremaster  is  found 
beliiiul  as  woll  as  in  front  and  at  the  sides  of  the  cord,  etc. 

Inguinal  hernia  is  the  passage  of  one  or  more  of  the  abdominal 
viscc'i-a  thrcMigh,  or  partly  through,  the  abdominal  wall,  following  in 
whole  or  in  part  the  inguinal  canal.  AN'lion  coiiijjhtc,  it  omergcs  at  the 
external  ring.  There  are  tv:o  principal  (jroups  of  inguinal  herniae 
according  as  the  point  at  which  they  pass  through  the  transversalis 
fascia  lies  cvternal  or  infernal  to  the  deep  epic/astric  artcnj. 

Inguinal  Fossae.  (Fig.  66.) — As  we  look  at  the  peritoneal  surface 
of  the  abdominal  wall  in  the  inguinal  region  we  see  on  each  side  two 
longitudinal  ridges  or  folds  of  the  peritoneum,  which  converge  as  they 
ascend  toward  the  umbilicus  where  they  meet  a  median  fold,  due  to  the 
urachus  raising  up  the  peritoneum.  The  most  lateral  i'old  is  the  plica 
epif/dsfriva,  a  fold  of  peritoneum  elevated  by  the  deep  epigastric  artery 
and  forming  the  lateral  boundary  of  II('s.selbach'.s  triaiu/le.  Somewhat 
nearer  the  middle  line  is  the  plica  hypof/astrica,  due  to  the  obliterated 
hypogastric  artery. 

In  the  inguinal  region  these  elevated  folds  mark  off  certain  <hj)rcx- 
sions  or  fossa'.  External  to  the  epigastric  fold  is  the  external  inguinal 
fossa,  at  the  bottom  of  which  we  see  a  funnel-shaped  depression  of 
the  peritoneum,  which  corresponds  to  the  internal  abdominal  ring. 
Through  the  peritoneum  we  can  usually  see  the  vas  deferens,  coming 
from  within  and  looping  around  the  epigastric  artery  to  enter  the  ring, 
where  it  joins  the  spermatic  vessels  coming  from  al)ove.  Between  the 
epigastric  and  hypogastric  folds  is  the  middle  inguinal  fossa,  which 
corresponds  to  the  rear  wall  of  the  inguinal  canal  as  far  as  the  outer 
half  of  the  external  ring,  and  is  formed  by  the  weaker  part  of  the 
transversalis  fascia.  Between  the  hypogastric  fold  and  the  outer 
border  of  the  rectus  muscle  is  the  internal  inguinal  fossa,  corresponding 
to  the  inner  half  of  the  external  ring. 

When  a  hernia  pushes  through  in  the  external  fossa  we  call  it  an 
external,  indirect  or  oblique  inguinal  hernia ;  when  in  the  middle  or 
internal  fossa,  it  is  known  as  an  internal  or  direct  inguinal  hernia. 
These  two  primary  varieties  of  inguinal  hernia  are  named  internal  and 
external  with  reference  to  the  relation  of  the  neck  of  their  sacs  to  the 
deep  epigastric  artery,  and  direct  and  indirect  or  oblique  with  reference 
to  their  straight  or  obli((ue  course  through  the  parietes.  The  resistance 
of  the  abdominal  wall  is  less  at  these  fossic  than  elsewhere. 

External,  Indirect  or  Oblique  Inguinal  Hernia. — This/o//o/r.s' the 
course  oi'  the  inguinal  canal.  An  incoinjtfiic  hernia,  or  one  not  passing 
beyond  or  only  just  beyond  the  external  ring,  is  called  a  bubonocele 
from  the  bubo-like  swelling.  A  complete  hernia  sooner  or  later  descends 
into  the  scrotum  and  is  called  scrotal.  At  the  external  ring,  as  in  the 
canal,  it  lies  in  front  and  slightly  to  the  outer  side  of  the  cord  which 
it  follows  to  the  scrotum.  The  coverings  of  such  a  hernia  are  the  same 
as  those  of  the  cord  in  the  same  situation,  /.  e.,  skin,  superficial  fascia, 
intercolumnar  fascia  (also  called  external  spermatic  fascia),  crema.steric 
fascia,   infundibuliform    fascia   (sometimes  called    internal   spermatic 


264  THE  ABDOMEN. 

fascia).  The  last  three  layers  form  what  is  sometimes  known  as  the 
fascia  propria,  a  term  of  no  great  importance.  The  serous  sac  is  de- 
rived from  the  peritoneum  at  the  bottom  of  the  external  fossa,  and  is 
separated  from  the  fascial  layer  by  subserous  tissue. 

These  hernise  are  pear-shaped,  with  the  small  end  above,  at  the 
narrow  oblique  neck  in  the  canal.  The  contents  are  not  characteristic  ; 
almost  any  of  the  lower  movable  viscera  may  be  within  the  sac.  Small 
intestine  is  commonly  found,  omentum  often,  and  the  latter  is  apt  to 
adhere  to  the  sac  and  make  the  contents  irreducible.  Not  infrequently, 
especially  in  congenital  herniie,  the  csecum  and  vermiform  appendix  are 
found  in  hernise  on  the  right  side. 

Despite  the  long  and  oblique  course  of  the  neck  of  external  inguinal 
hernice,  in  a  canal  whose  muscular  walls  would  naturally  tend  to  close 
it,  and  despite  the  more  direct  course  of  internal  inguinal  herniae 
through  an  anatomically  weaker  part  of  the  abdominal  wall,  the 
former  occur  much  more  commonly.  They  are  especially  common  in 
early  life  and  this  fact,  as  well  as  their  greater  frequency,  is  to  be  ex- 
j)lained  in  great  measure  by  congenital  conditions.  In  foetal  life  one 
ring  lies  in  front  of  the  other,  to  facilitate  the  passage  of  the  testes,  so 
there  is  scarcely  any  canal.  In  early  childhood  the  inguinal  canal 
passes  more  directly  and  less  obliquely  through  the  abdominal  wall 
than  in  the  adult,  a  fact  which  favors  the  formation  of  hernise.  The 
adult  obliquity  of  the  canal  is  acquired  only  after  the  development  of 
the  pelvis  is  completed. 

Preceding  the  descent  of  the  testis  from  the  region  of  the  kidney 
into  the  scrotum  a  pouch  of  peritoneum,  the  proc&S's»s  vaginalis,  descends 
through  the  abdominal  wall  where  the  canal  is  to  be,  and  reaches  the 
scrotum  where  it  is  to  form  the  tunica  vaginalis  testis.  After  the 
testis  has  reached  the  scrotum,  in  the  eighth  month  of  foetal  life,  the 
neck  and  upper  part  of  the  pouch,  down  to  the  upper  end  of  the  epi- 
didymis, tend  to  become  closed.  It  is  normally  reduced  to  a  small 
cord  of  fibrous  tissue,  lying  among  the  elements  of  the  cord,  which  is 
attached  to  the  bottom  of  the  funnel-shaped  depression  of  peritoneum 
in  the  external  fossa.  This  closure  proceeds  usually /roj/i  two  points, 
the  internal  ring  and  just  above  the  epididymis,  commencing  as  a  rule 
at  the  former  point.  Part  of  the  pouch  between  these  two  points  may 
remain  open  and  give  rise  to  an  "  encysted  hydrocele  of  the  cord,"  if 
fluid  collects  in  it. 

Varieties  of  External  Oblique  Inguinal  Hernia  due  to  Congen- 
ital Defects  in  the  "  Vaginal  Process." — 1.  Sometimes  the  vaginal 
process  does  not  close  but  remains  continuous  with  the  peritoneal 
cavity.  A  hernia  may  descend  into  this  process  as  a  sac  whicli  is  pre- 
formed or  congenital.  Hence  this  variety  is  known  as  congenital  in- 
guinal hernia.  Such  a  hernia  need  not  occur  at  once  or  even  shortly 
after  birth.  It  may  develop  after  some  years,  in  which  case  the  upper 
opening  of  the  process,  remaining  constricted  or  closed  by  a  thin  sep- 
tum, is  dilated  or  torn  by  the  hernia  forced  through  it  by  some  sudden 
strain.     It  may  even  occur  when  the  testis  has  not  descended,  pro- 


VARIETIES   OF  EXTERNAL   ISGUINAL   HERNIA. 


265 


vided  the  proces^jll^s  vaginalis  has  passed  into  the  scrotum.  In  con- 
genital herniffi  the  sac  is  very  thin,  the  neck  long  and  narrow,  and  the 
parts  about  it  have  been  little  disturbed  or  distended  so  that  drangu- 
lation  is  relatively  more  frequent  and  severe  in  this  variety  than  in  the 
acquired  form.  Reduction  by  taxi><  may  l)e  diffirxlf  by  reason  of  its 
long  narrow  neck.  As  the  natural  tendency  of  a  congenital  sac  is  to 
close  during  early  life,  especially  as  the  canal  grows  longer  and  more 
oblicpie,  we  can  often  eifect  a  cure  in  children  by  keeping  the  contents 
permanentlv  reduced. 

Fig.  68. 


Diagrammatic  representation  of  the  varieties  of  external  inguinal  hernia  due  to  congenital  defects 
in  the  v-acinal  i)rocess.  1,  the  processus  vaginalis  showing  the  two  points  where  closure  of  the  upper 
part  commences,  atC  and  C  ;  2,  congenital  hernia  ;  3,  hernia  into  the  funicular  process  ;  4,  infantile 
hernia;  5,  acquired  hernia.  E,  external  abdominal  ring;  I,  internal  abdominal  ring;  P.S.,  peri- 
toneal sac';  B,  herniated  bowel ;  F.P.,  funicular  process  ;  T,  testis. 

2.  The  upper  end  of  the  vaginal  process  may  close  while  the  rest 
remains  open,  a  condition  which  is  the  rule  in  early  inftuicy.  If 
under  such  circumstances  a  hernia  with  its  peritoneal  sac  is  forced 
down  or,  according  to  Lockwood's  theory,  a  peritoneal  sac  is  drawn 
down  by  the  gubernaculum,  such  a  hernia  is  called  an  infantile  inguinal 
hernia,  for  it  was  first  described  in  infiints. 

As  the  sac  lies  behind  the  open  vaginal  process  we  must  pass 
through  the  process  to  open  the  sac,  and  in  so  doing  we  would  dicide 
three  layers  of  peritoneum,  two  of  the  process  and  one  of  the  sac.  The 
variety  is  uncommon  and  unimportant.  The  hernial  sac  may  occasion- 
ally project  into  or  invaginate  the  vaginal  process,  giving  rise  to  the 
term  encysted  hernia. 

3.  Again  the  closure  of  the  vaginal  process  may  occur  only  below, 
just  above  the  testis,  and  a  hernia  into  this  preformed  sac  is  known  as 
a  hernia  into  the  funicular  process. 

This  sac  is  congenital  and  it  differs  from  the  so-called  congenital 
hernia  only  in  the  fact  that  in  the  latter  the  contents  are  in  contact 
with  the  testicle,  in  the  former  they  are  separated  by  the  septum  which 
has  shut  off  the  testicular  pouch.  Hernii^  which  become  fully  formed 
in  a  short  time  are  of  congenital  origin. 

4.  Finally  those  hernia?  whose  sac  is  formed  anew  from  the  peri- 
toneum of  the  external  fossa  are  known  as  acquired  external  inguinal 
hernise.     This  variety  develops  more  slowly  and  does  not  de.-cend  as  low 


266  THE  ABDOMEN. 

in  the  scrotum  or  come  in  sucli  close  contact  with  the  testis  as  the  con- 
genital varieties. 

Internal  or  direct  inguinal  hernia  is  one  which  emerges  internal 
to  the  deep  epigastric  vessels  and,  as  its  name  implies,  passes  directly 
forward  through  the  abdominal  wall  where  it  appears  to  be  weakest. 
Nevertheless  it  is  far  less  common  than  the  indirect  form,  a  fact  due  to 
congenital  conditions,  the  presence  of  the  cord  in  the  canal  and  the  fun- 
nel-shaped depression  of  peritoneum  at  the  internal  ring  which  act  as 
predisposing  causes  of  the  indirect  variety.  Direct  hernia  occurs  most 
often  when  the  abdominal  walls  have  lost  their  strength  and  are  lax,  as 
in  old  age,  after  any  prolonged  distension,  or  after  emaciation  follow- 
ing obesity.  Its  jjolnt  of  entry  is  usually  in  the  middle  inguinal  fossa 
opposite  the  external  ring,  rarely  in  the  internal  fossa,  in  which  case 
it  has  been  called  "  internal  oblique  hernia^'  as  its  course  is  somewhat 
obliquely  outward  to  emerge  at  the  external  ring.  The  neck  of  a  direct 
hernia  is  usually  loide,  admitting  one  or  two  fingers,  so  that  the  pulsa- 
tion of  the  deep  epigastric  artery  can  be  readily  felt  to  its  outer  side 
and  strangulation  is  not  common,  occurring  most  often  at  the  external 
ring.  Its  coverings  differ  only  nominally  from  those  of  the  external 
variety.  TransversaUs  fascia  takes  the  place  of  that  local  subdivision  of 
it,  the  infundibuliform  fascia.  In  place  of  the  cremasteric  fascia  we 
have  the  conjoined  tendon,  except  in  certain  cases  where  the  hernia 
escapes  beneath  or  breaks  through  between  its  fibers  without  receiving 
a  covering.  If  it  escapes  through  the  inner  fossa  the  triangular  liga- 
ment may  form  one  of  its  coverings. 

Other  features  of  this  form  of  hernia  may  be  best  brought  out 
by  observing  the  differences  between  internal  and  external  inguinal 
hernia. 

The  sJiape  of  an  internal  inguinal  hernia  is  globular  on  account  of 
its  short  neck,  that  of  an  external  is  pear-shaped. 

The  size  of  the  former  is  smaller  and  it  has  little  tendency  like 
the  latter  to  follow  the  cord  or  descend  low  into  the  scrotum.  The 
position  of  the  former  is  more  internal,  and  it  lies  more  internal  to  and 
in  front  of  the  cord  instead  of  in  front  of  and  external  to  it.  On  reduc- 
tion the  track  of  the  neck  of  the  internal  is  short  and  straight,  that  of 
the  external  is  oblique  and  longer.  Also  if  the  finger  can  be  intro- 
duced to  their  deep  openings,  the  pulsations  of  the  deep  epigastric  artery 
may  be  felt  internally  in  external  hernia  and  externally  in  internal 
hernia  ;  while  internally  in  the  latter  may  be  felt  the  edge  of  the  rectus 
muscle. 

The  external  form  is  often  congenital,  the  internal  never.  The 
external  form  occurs  especially  in  early  life,  the  internal  late  in  life. 

From  these  differences  it  would  seem  an  easy  matter  to  distinguish 
between  the  two  forms,  and  so  it  is  where  the  relations  of  the  various 
parts  are  not  much  disturbed,  as  in  recent  or  congenital  hernise.  But 
in  old  external  inguinal  hernia  the  traction  of  an  increasing  weight  on 
the  inner  side  of  the  internal  ring  enlarges  it  on  its  internal  aspect  and 
so  shortens  the  canal  and  makes  it  less  obli(jue.     Also  if  the  rupture  is 


HERNIA   OPERATIONS.  267 

irreducible  some  of  the  diagnostic  points  will  he  wanting.  Thus  it 
may  be  difficult  or  impossible  to  distinguish  between  the  two  varieties. 

Hernia  Operations. — The  incision  over  the  course  of  the  canal,  and 
for  a  short  distance  internal  to  it,  is  laid  out  according  to  the  land- 
marks Ave  have  given  for  the  canal,  and  the  visible  or  palj)able  position 
of  the  hernia.  The  superficial  external  pudic  artery  is  usually  divided 
but  is  of  no  importance.  Several  large  veins,  varying  in  size  and  num- 
ber, may  be  met  with  crossing  the  line  of  incision.  In  recent  or  small 
external  hernise  the  point  of  constriction,  if  strangulation  occurs,  may 
be  at  the  internal  or  external  ring,  but  it  is  more  often  in  the  narrow 
neck  of  the  sac  itself,  which  must  then  be  opened. 

In  the  operation  most  often  practised,  that  of  Bassini,  the  dilated  or 
enlarged  canal  is  obliterated,  so  as  not  to  leave  an  easy  passage  way 
for  the  recurrence  of  the  hernia,  and  a  new  track  is  made  for  the  cord. 

How  are  We  to  Recognize  the  Different  Layers  ? — It  is  neither  neces- 
sary or  always  possible  to  distinguish  all  of  them.  After  division  of 
the  skin  whatever  moves  with  the  cut  edges  belongs  to  the  superficial 
fascia,  unless  inflammation  has  rendered  the  latter  adherent  to  the  parts 
beneath.  The  external  oblique  aponeurosis  can  easily  be  told  by  its 
pearly  shining  oblique  fibers.  The  cremaster  or  conjoined  tendon  is 
the  only  muscle  divided,  and  hence  may  be  recognized.  Some  diffi- 
culty may  be  found  in  determining  whether  the  peritoneal  sac  has  been 
opened  or  not. 

In  congenital  inguinal  hernise  the  sac  is  closely  adherent  to  the 
fascial  layer  outside.  This  may  enable  us  to  know  when  we  meet  with 
such  a  hernia,  but  it  makes  it  more  difficult  to  free  the  sac  as  well  as 
to  know  when  we  have  opened  it. 

Iloir  are  loe  to  (Ji.-ifinr/uish  between  the  sac  and  the  intestinal  vail / 

1.  The  outside  of  the  sac  has  not  a  shiny  sniootJi  surface,  like  that  of 
the  peritoneal  surface  of  the  intestine,  but  often  shows  attached  to  it 
little  lumps  of  fat  belonging  to  the  subperitoneal  tissue. 

2.  The  vessels  on  the  sac  run  more  vertically,  those  on  the  intestine, 
circularly. 

3.  If  we  pinch  up  a  fold  between  the  fingers  the  sac  is  veri/  thin, 
the  intestinal  wall  thicker.  The  presence  o{  fluid  within  the  sac,  in 
large  amount  in  strangulated  hernia,  is  also  of  great  diagnostic  im- 
portance. 

In  what  direction  should  we  not  incise  to  relieve  a  constriction  of 
the  neck  of  an  inguinal  hernia?  In  the  external  form,  not  backwards 
on  account  of  the  cord,  nor  inwards  on  account  of  the  deep  epigastric 
artery.  In  the  internal  form,  not  backwards  on  account  of  the  vas 
deferens  and  blood  vessels,  nor  outwards  for  fear  of  the  deep  epigastric 
artery.  But  as  it  is  often  impossible  to  distinguish  between  the  two 
forms  it  is  advisable  in  any  case  to  incise  as  if  it  might  be  either 
variety,  and  not  to  cut  backward,  inward,  or  outward. 

Hence  we  should  incise  u/iirardor  upirard  and  slii/Jiflif  iiurard,  i.  c, 
parallel  with  the  deep  epigastric  artery.  An  extensive  cut  is  unneces- 
sary, several  small  cuts  answer  equally  well. 


268  THE  ABDOMEN. 

The  Length  of  the  Mesentery  in  its  Relation  to  the  Formation  of 
the  Hernia, — Mr.  Lockwood  has  shown  :  (1)  That  witii  a  me.^entei-y  of 
normal  length  the  intestine  may  be  drawn  down  through  the  external 
ring  but  not  into  the  scrotum.  (2)  That  the  mesentery  is  relatively 
longer  in  infancy,  decreasing  rapidly  in  the  second  year,  and  averaging 
eight  inches  in  length  in  the  adult.  In  the  congenital  herni?e  of  infancy 
the  mesentery  may  allow  the  gut  to  descend  into  the  scrotum  without 
first  becoming  lengthened,  as  is  necessary  in  adults. 

An  interstitial  inguinal  hernia  is  one  into  and  not  through  the  hdly 
tcall.  It  usually  starts  as  an  external  hernia  but  instead  of  passing  out 
through  the  external  ring  it  makes  its  way  between  some  of  the  layers 
of  the  abdominal  wall.  This  form  of  hernia  is  most  apt  to  occur  when, 
for  some  reason,  the  external  ring  is  narrower  than  normal  or  is  closed. 
These  conditions  are  present  when  the  testicle  has  not  completely 
descended  but  is  lodged  just  above  or  within  the  inguinal  canal.  The 
latter  position  of  the  testis  most  favors  the  production  of  such  a  hernia, 
for  the  upper  end  of  the  canal  is  enlarged  and  commonly  occupied  by 
a  pouch  of  peritoneum. 

In  such  a  hernia  the  tumor  is  flattened  out.  According  to  Tillaux, 
strangulation  may  occur  by  compression  of  the  surrounding  muscular 
layers,  and  taxis  is  more  harmful  than  useful. 

Reduction  en  Masse. — A  hernia  may  be  reduced  by  taxis  together 
with  its  sac  so  that  any  constriction  in  the  neck  of  the  sac  still  exists. 
In  such  cases  the  sac  may  be  pushed  up  between  the  peritoneum  and 
the  abdominal  walls  or,  if  the  iufundibuliform  covering  is  ruptured, 
in  front  of  or  behind  the  conjoined  tendon  which  forms  the  upper  boun- 
dary of  the  canal. 

Inguinal  Hernia  in  the  Female. — A  pouch  of  peritoneum,  the 
canal  of  ^11  i:h,  corresponding  to  the  vaginal  process  of  the  male,  de- 
scends in  foetal  life  for  some  distance  along  the  round  ligament  and 
when,  as  sometimes  happens,  it  remains  open  it  may/orm  the  sac  of  a 
congenital  hernia. 

Inguinal  hernia  in  the  female  is  most  common  in  infancy,  early 
childhood  or  after  the  first  pregnancy.  In  the  former  case  it  is  con- 
genital, in  the  latter  acquired,  the  canal  having  become  distended  dur- 
ing pregnancy  by  the  enlargement  of  the  cord,  which  shrivels  after 
childbirth  but  leaves  the  canal  more  lax.  The  round  ligament  bears 
the  same  relation  to  the  hernial  sac  as  does  the  cord  in  the  male. 

After  emerging  at  the  external  ring  a  hernia  may  pass  down  into 
the  labium  majus.  The  coverings  are  the  same  as  in  the  male  except 
that  the  cremasteric  layer  is  wanting.  The  contents  are  also  the  same 
except  that  the  ovary  or  even  the  uterus,  in  part,  may  be  found  in  the 
sac.      Internal  inguinal  hernia  is  very  rare  in  women. 

Operations  in  this  region,  except  for  hernia,  are  chiefly  those  to 
shorten  the  round  ligaments,  to  open  abscesses,  or  to  tie  the  external 
iliac  artery.  To  shorten  the  round  ligament  the  incision  is  made  as  for 
hernia  or  a  little  more  horizontally.  The  external  ring  is  exposed,  the 
tissue  lying  just  internal   to  it  is  hooked  up  with  a  blunt  hook  and 


INGUINO-FEMORAL  REGION  AND  FEMORAL  HERNIA.       209 

the  round  ligament  is  sought  for  in  this  tissue.  If  the  ligament  can 
not  be  so  found,  tiie  canal  should  be  slit  up  and  its  contents  caught  up 
on  the  hook.  After  pulling  it  down  for  a  certain  distance,  the  liga- 
ment becoming  more  flesiiy  and  thick,  a  double  sheath  of  peritoneum 
is  drawn  down  with  it.  The  latter  may  predispose  to  subsequent 
hernia. 

Abscesses  are  principally  of  hco  varieties,  to  be  spoken  of  in  the 
study  of  the  iliac  fossa.  One  variety  is  in  the  snhperitonea/  tiaHiic  of 
the  iliac  fossa  and  is  limited  inferiorly  by  the  line  of  Poupart's  liga- 
ment. Here  it  raises  up  the  peritoneum  and  may  be  inciHcd,  just 
above  Poupart's  ligament,  without  opening  the  peritoneum.  The  otlier, 
psoas  abscess,  is  hencath  the  iliac  fascia  and  raai/  paint  above  or  lx*lo\v 
the  middle  or  outer  half  of  Poupart's  ligament.  When  above  the  liga- 
ment it  may  be  exposed  and  opened  after  incising  the  transversal  is 
fascia  and  pushing  up  the  lower  limit  of  the  peritoneum,  thus  bringing 
to  view  the  iliac  fascia. 

AVe  proceed  in  a  similar  way  to  expose  the  external  iliac  artery,  for 
which  see  Iliac  Region,  p.  270. 

The  Inguino -femoral  Region  and  Femoral  Hernia. 

This  region  is  the  passarje  tray  between  the  upper  part  of  the  thigh 
and  tiie  region  above.  Poupart^'i  lifjament  bridges  across  the  concave 
iliopubic  margin  of  the  hip  bone  and  thereby  forms  a  space,  mainly 
occupied  by  the  iliopsoas  muscle  and  the  external  iliac  vessels  in  pass- 
ing into  the  thigh.  The  fascia  investing  these  structures  subdivides 
the  space  into  compartments  or  lacunae. 

The  largest  and  most  external  of  these  is  the  muscular  compartment 
occupied  by  the  iliopsoas  muscle  and  the  anterior  crural  and  external 
cutaneous  nerves.  It  is  bounded  externally  and  behind  by  the  bony 
iliac  margin  between  the  anterior  superior  spine  and  the  iliopectineal 
eminence;  in  front  by  Poupart's  ligament,  and  internally  by  the  ih'ac 
fascia.  This  fascia  is  firmly  attached  to  the  transversal  is  fascia  and 
Poupart's  ligament  along  the  outer  4  cm.  of  the  latter,  but  then  sep:i- 
rates  from  them  to  pass  to  the  iliopectineal  eminence,  where  it  is  con- 
tinuous with  the  pectineal  fascia,  /.  e.,  the  pubic  portion  of  the  fascia 
lata.  It  is  in  this  compartment  that  a  psoas  abscess  passes  beneath 
Poupart's  ligament  to  "  point "  below  it. 

The  pectineus  muscle  passes  up  a  short  distance  above  Poujiart's 
ligament  and  may  be  said  to  occupy  a  pectineal  compartment,  liinited 
behind  by  the  horizontal  pubic  ramus  and  in  front  by  the  pectineal 
fascia.  The  upper  limit  of  this  fascia,  along  the  iliopectineal  line,  is 
thickened  by  transverse  fibers  from  Gimbernat's  ligament  to  fi^'m  what 
is  known  as  Cooper's  lir/ament. 

The  rest  of  the  space  is  frianc/ular  in  shape  and,  save  the  inner 
angle  occupied  by  Gimbernat's  ligament,  constitutes  the  vascular  com- 
partment. 

This  is  boKtidrd  \n  front  by  Poupart's  ligament  (/.  r.,  the  superjicial 
femoral  arch)  and  the  transversalis  fascia,  attached  to  Poupart's  liga- 


270  THE  ABDOMEN. 

ment,  which  is  thickened  by  transverse  fibers  and  known  as  the  deep  fem- 
oral arch.  Behind  the  compartment  are  the  iliac  and  pectineal  fasciae, 
continuous  with  one  another.  The  external  iliac  vessels  and  the  cru- 
ral branch  of  the  genitocrural  nerve  occupy  this  compartment  in  their 
passage  into  the  thigh,  the  vein  lying  internal  to  the  artery. 

The  vessels  do  not  occupy  the  entire  compartment,  but  there  is  an 
interval  of  3/5-1  inch  between  the  vein  and  the  outer  margin  of  Gim- 
bernat's  ligament,  which  constitutes  the  femoral  ring,  through  which  a 
femoral  hernia  forces  its  way  beneath  Poupart's  ligament. 

In  passing  beneath  Poupart's  ligament  into  the  thigh  to  become  the 
femoral  vessels  the  e.rternal  iliac  vessel.^-  carry  irith  them  a  fascial 
sheath,  the  femoral  sheath,  which  bounds  the  vascular  compartment 
and  is  continuous  with  the  fascia  lining  the  abdomen,  /.  e.,  the  trans- 
versalis  fascia  in  front  and  the  iliac  fascia  behind.  These  fasciae  are 
continuous  with  one  another  internally  and  externally  so  as  to  form  a 
complete  sheath.  This  sheath  is  funnel-shaped,  wide  above  but  closely 
embracing  the  vessels  below,  where  it  is  continuous  with  their  proper 
sheath.  The  width  of  the  sheath  beneath  Poupart's  ligament  prevents 
compression  of  the  vein  and  pinching  or  stretching  of  the  vessels  in 
movements  at  the  hip. 

The  vessels  occupy  the  outer  side  of  the  funnel  and  leave  a  pyramidal 
space,  the  femoral  canal,  on  the  inner  side  of  the  vein  and  separated 
from  it  by  connective  tissue,  belonging  to  the  fibrocellular  or  proper 
sheath  of  the  vessels.  This  canal  measures  one  half  to  three  fourths 
inch  in  length,  and  tapers  to  its  louder  closed  end  which  is  opposite  the 
upper  end  of  the  saphenous  opening.  It  is  only  2,  potential  canal,  like 
the  inguinal,  not  a  real  one  unless  made  so  by  a  hernia  or  the  knife. 
It  represents  a  iceak  spot  which  forms  the  passage  way  of  a  femoral 
hernia. 

The  femoral  canal  is  hounded  externally  by  the  femoral  vein  with  a 
septum  of  connective  tissue  between,  and  on  the  other  sides  by  the  fem- 
oral sheath.  It  contains  fatty  and  cellular  tissue,  lymphatics  penetrating 
its  anterior  wall  and  passing  from  the  superficial  to  the  deep  inguinal 
nodes,  and  one  or  more  lymph  nodes.  Its  upper  or  abdominal  aperture 
is  i\\Qo\di\  femoral  riwj,  mentioned  above.  The  size  of  the  ring  varies, 
but  is  usually  sufficient  to  admit  the  tip  of  the  forefinger.  It  averages 
three  fifths  of  an  inch  in  diameter  in  the  male  and  is  half  again  as  large 
in  the  female,  hence  the  greater  frequency  of  femoral  hernia  in  iroinen  in 
the  ratio  of  three  to  one.  Its  grecder  width  in  tvonien'is  not  due  to  any 
greater  width  of  the  space  beneath  Poupart's  ligament,  for  it  is  not 
wider,  but  to  the  smaller  size  of  the  muscles,  occupying  the  muscular 
compartment,  and  of  Gimbernat's  ligament. 

When  vieu-ed  from  above  the  femoral  ring  is  seen  to  l)e  covered  by 
peritoneum,  which  may  present  a  slight  de])ression,  the  foKsa  femorrUis. 
According  to  Tillaux,  such  a  depression  is  not  normal  but  ])athological, 
the  peritoneum  being  drawn  down  by  an  attached  fat  lobule  belonging 
to  the  subperitoneal  tissue. 

On  removing  the  peritoneum  the  ring  is  seen  to  be  closed  by  the 


BELATIOXS  OF  PARTS  ABOUT  THE  RIXG. 


271 


septum  cnirale  (Cloquet),  a  condensed  layer  of  connective  tissue,  con- 
tinuous with  the  subperitoneal  tissue  and  perforated  hy  lymphatics 
passing  from  the  inguinal  to  the  iliac  nodes.  A  small  h/mp/i  node  is 
sometimes  found  lying  on  it.  Inflammation  of  this  gland  or  of  one 
in  the  canal  has  been  mistaken  for  strangulated  hernia,  on  account  of 

a  similarity  of  symptoms. 

Fig.  69. 


ANT. -SUP. 
ILIAC    SPINC 


ANT.    CRURAL 
NERVE 


Section  of  the  crural  caoal  and  of  the  n)u>cular  and  vascular  com  part  meDts  beneath  Poupart's 

ligameut.     (Tillacx.) 

The  boundaries  of  the  ring  are  of  great  practical  importance  from 
their  relation  to  the  neck  of  a  femoral  hernia.  To  the  outer  side  lies 
the  vein  in  its  sheath,  elsewhere  the  boundaries  are  of  firm  fibrous 
structures.  //*  front  lies  the  sujx^rficial  femoral  arch  (Poupart's  liga- 
ment; and  the  deep  femoral  arch  (see  p.  270).  Behind  is  the  thin  upper 
end  of  the  pectineus  muscle,  resting  on  the  horizontal  pubic  ramus  and 
covered  by  the  thickened  upper  end  of  the  pectineal  fascia.  Interna// 1/ 
there  is  a  series  of  firm  fibrous  structures,  attached  to  the  iliopectineal 
line,  as  follows  from  below  upward  :  the  iliac  jwrtiou  of  the  fascia  lata, 
Gimbernat's  ligament,  the  triangular  ligament,  the  conjoined  tendon, 
and  the  deep  femoral  arch.  These  structures  present  a  sharp  free  mar- 
gin towards  tlie  ring. 

Relation  of  Parts  About  the  Ring. — The  ftpermatic  cord  in  the 
male  and  the  round  /ir/ament  in  the  female  lie  in  loose  tissue  one  fourth 
to  one  fifth  of  an  inch  above  the  anterior  mare/in  of  the  ring.  The 
epif/nMrie  ve-^selx  lie  above  and  to  its  outer  side,  distant  about  half 
an  inch.     The  small  pubic  l)ranch  of  this  artery  runs  across  in  front 


272  THE  ABDOMEN. 

of  the  ring,  to  ramify  on  the  upper  aspect  of  Gimbernat's  ligament. 
These  structures  are  in  danger  of  being  divided  by  a  free  incision  up- 
wards but,  according  to  Tillaux,  not  by  an  incision  or  incisions  of  one 
fifth  of  an  inch,  which  may  subsequently  be  enlarged  by  the  finger. 

The  internal  and  posterior  aspcet  of  the  ring  are  usually  free  from 
important  relations.  Therefore  to  relieve  the  constriction  in  a  strang- 
ulated hernia  we  may  incise  bachcard,  but  little  room  is  to  be  gained 
here  as  only  a  thin  layer  of  soft  parts  covers  the  bone.  Hence  we 
incise  inwards,  bearing  in  mind  the  following  variations. 

Once  in  every  3|  cases  the  obturator  artery  is  given  off  as  a  branch 
of  the  epigastric  artery.  The  course  of  this  branch  is  commonly  to  the 
outer  side  of  the  ring,  where  it  lies  close  to  the  vein,  and  not  exposed 
to  injury  by  incision,  for  we  never  incise  outwards  on  account  of  the 
vein.  Occasionally  (in  1  to  3J  psr  cent.)  the  common  trunk  is  longer, 
crossing  in  front  of  the  ring,  and  the  obturator  branch,  with  its  vein, 
passes  back  close  to  the  in)ter  border  of  the  ring  where  artery  and  vein 
are  exposed  to  injury  by  a  free  incision  inwards.  Cases  are  recorded 
where  such  an  injury  has  resulted  fatally,  and  the  reason  why  it  is  not 
more  frequent  seems  to  be  that  the  vessels  lie  in  loose  tissue,  1  to  2^ 
lines  from  the  edge  of  the  ring,  and  may  be  readily  pushed  back  before 
the  knife,  and  also  that  multiple  short  incisions  are  often  employed. 

If  the  finger  can  be  pushed  through  the  ring  the  pulsation  of  such  an 
aberrant  artery,  lying  internally,  may  he  felt.  It  should  be  sought  for 
so  as  to  avoid  the  chance  of  an  accident. 

The  size  and  the  tension  of  the  femoral  ring  and  canal  and  of  the 
saphenous  opening,  and  hence  the  constriction  of  a  hernia  passing 
through  them,  varies  with  the  position  of  the  limb.  They  are  enlarged 
and  relaxed  in  flexion,  adduction,  and  inward  rotation  of  the  thigh  and 
hence  taxis  should  be  tried  in  this  position.  In  the  reverse  position 
these  parts  are  rendered  tense  by  the  traction  of  the  fascia  lata  upon 
Poupart's  ligament. 

Femoral  hernia  is  ahrays  acquired,  never  congenital.  It  occurs 
almost  exclusively  in  adult  life.  Though  more  common  in  women 
than  in  men  in  the  ratio  of  3  to  1 ,  it  is  less  common  in  iromen  than  the 
inguinal  variety,  contrary  to  the  general  impression.  The  weakening 
effect  of  pregnancy  on  the  abdominal  walls  increases  the  liability  of 
women  to  femoral  hernia,  so  that  it  is  more  common  after  the  first 
pregnancy. 

Course  and  Coverings. — A  pouch  is  gradually  formed  of  the  peri- 
toneum covering  the  weak  spot,  the  femoral  ring.  This  forms  the 
hernial  sac  and  a  covering  is  received  from  the  septum  crurale  in  pass- 
ing through  the  ring  beneath  Poupart's  ligament.  The  hernia  descends 
vertically  in  the  femoral  canal  to  its  lower  end,  opposite  the  saphenous 
opening.  Here  it  turns  fonrard  and  then  upu-ard  and  outn-ard  toward 
the  anterior  superior  iliac  spine,  even  as  far  as  Poupart's  ligament, 
receiving  a  covering  from  the  femoral  sheath  and  the  cribriform  fascia. 
It  thus  comes  to  lie  beneath  the  skin  and  subcutaneous  tissue. 

Various   recvions  have  been  adduced  to  explain  the  curved,  course  of 


PLATE   XXXI  J  1 


FIG.  67. 


SAC    OF    FEMOaflL 
HERN  I* 


DEEP    EPiGAST. 
.  r      S  E  LS 


INTERNAL 

A  BOOM.         -TU- 
RING      ,:.;  ^' 


SAC    OF    EXT. 

,  I NGUINAL 

-  :  =  N  I A 


GIMBEB 
NAT'S 
LIG. 

ABNOR. = 

ORIGINS 
OF    OB- 
TURATOR 
ARTERY 

OBTURATOR 
NERVE 


PQUPART-S 
LIGAMENT 


EXT.    ILIAC 
/ VESSELS 


LIOPSOAS 


VAS    DEFERENS 


VES.    SEMINAL 


Rear  view  of  anterior  abdominal  ^A^all,  showing  right  inguinal 
and  left  femoral  hernia.  The  obturator  artery  is  given  off  by  the 
epigastric,  the  dotted  line  on  the  left  showing  another,  rarer  and 
more  important  form  of  this  variety.     (Joessel.) 


HERNIOTOMY.  273 

the  hernia.  (1)  The  canal  curves  slightly  with  the  CKncavity  forward. 
(2)  The  downward  course  is  limited  by  the  lower  limit  of  the  canal 
and  the  firmness  of  the  lower  margin  of  the  saphenous  ojxMiing  which 
is  closely  united  with  the  femoral  sheath  and  the  cribriform  fascia. 
(o)  The  constant  flexion  of  the  thigh.  (4)  The  loops  formed  by  the 
vessels  passing  down  to  the  saphenous  opening  loop  uj)  and  jirevent 
the  descent  of  a  hernia,      (o)  The  traction  of  the  mesentery. 

The  cour.se  of  a  hernia  should  be  honw  in  mind  in  (ippljinrj  ta.ci.H  in 
the  reverse  direction  for  its  reduction. 

From  the  above  we  may  summarize  the  coverings  from  without  as 
follows:  (1)  skin  ;  (2)  subcutaneous  tissue  ;  (3)  cribriform  fascia  ;  (4) 
anterior  wall  of  the  femoral  canal  (femoral  sheath) ;  (-5)  septum 
crurale  ;  (G)  peritoneal  sac. 

The  sac  of  such  a  hernia  comes  to  lie  very  close  beneath  the  skin. 
One  or  more  of  Xos.  3,  4  and  5  may  be  broken  through  instead  of 
j)ushed  before  the  hernia  so  as  to  be  wanting  as  a  covering,  and  the 
,torii  opening  of  such  layer  or  layers  may  be  the  seat  of  con.striction. 
Nos.  4  and  5  (or  3,  4,  and  5)  often  matted  together  and  combined  to 
form  a  single  covering,  were  called  fa.scia  propria  by  Sir  A.  Cooper. 
It  is  often  impossible  to  distinguish  the  separate  layers  as  they  may 
be  thinned  out  and  adlierent  to  one  another.  In  case  of  a  hernia  con- 
fined to  the  upper  part  of  the  canal,  the  iliac  portion  of  the  fascia  lata 
forms  a  covering  between  the  femoral  sheath  and  the  superficial  fascia 
in  the  place  of  No.  3. 

A  hernia  confined  to  the  canal  is  small,  owing  to  the  unvielding 
character  of  its  fibrous  walls,  and  is  generally  readily  reducible  as  the 
neck  is  as  large  as  the  rest  of  the  hernia.  After  protruding  at  the 
saphenous  o))ening  into  the  loose  subcutaneous  tissue  of  the  groin  a 
femoral  hernia  may  attain  considerable  size. 

The  contents  are  not  ciiaracteristic  ;  omentum  is  very  often  present 
and  apt  to  be  adherent,  intestine  is  less  often  present  than  in  inguinal 
hernia  but  is  more  likely  to  be  strangulated.  In  the  latter  case  the 
.seat  of  the  constriction  is  often  in  the  neck  of  the  sac,  but  more  often 
outside  of  it  than  with  the  inguinal  variety.  It  occurs  at  the  curved 
margin  formed  by  Gimbernat's  ligament,  etc.,  or,  according  to  some,  at 
the  margin  of  the  saphenous  opening. 

Herniotomy. — The  incision  may  be  parallel  to  Poupart's  ligament  and 
over  the  tumor,  or  vertical  and  on  its  inner  side.  Poupart's  ligament 
should  be  exposed  as  a  landmark.  In  large  herniie  the  overlying 
layers  may  be  few  in  number  or  much  thinned  out,  so  the  incision 
should  be  made  with  care.  The  amount  of  subperitoneal  fat  is  some- 
times very  great  so  as  to  simulate  omentum  MJiile  the  thinned  fascia 
l)ropria  may  be  mistaken  f  )r  the  sac.  In  such  a  case,  after  enlarging 
the  ring,  the  real  sac  embedded  in  fat  may  be  reduced  with  its  con- 
tents and,  if  the  constriction  be  in  the  neck  of  the  sac,  the  strangula- 
tion would  not  i)e  relieved.  In  operating  I  have  not  infrequentlv 
found  this  fat  so  abundant  that,  in  a  tumor  of  some  size,  it  was  not 
easy  to  find  the  small  sac.  We  incise  the  constriction  inwai-d,  inwaril 
18 


274  THE  ABDOMEN. 

and  backward,  or  inward  and  forward  (Cooper).  The  small  externa] 
pudic  vessels  lie  behind  the  hernia  and  therefore  are  not  cut  by  the 
incision. 

In  Bassini's  radical  operation,  after  removing  the  sac  high  up,  the 
canal  is  closed  by  suturing  the  inner  end  of  Poupart's  ligament  and  the 
falciform  edge  of  the  fascia  lata  to  the  pectineal  fascia  (/.  e.,  the  pubic 
portion  of  the  fascia  lata). 

In  the  diagnosis  between  femoral  and  inguinal  hernia,  Poupart's  lig- 
ament and  the  pubic  spine  are  the  two  important  landmarks.  The  neck 
of  a  femoral  hernia  is  below  the  former  and  external  to  the  latter  ;  that 
of  an  inguinal  hernia  has  the  opposite  relations,  though  it  often  crosses 
the  spine,  lying  in  front  of  it. 

The  diagnosis  is  easy  in  scrotal  hernise,  in  thin  subjects,  and  when 
the  hernise  are  reducible  so  that  the  relations  of  the  neck  of  the  sac  to 
the  landmarks  can  be  examined.  It  is  easier  in  men  than  in  women 
because  of  the  greater  ease  of  examining  the  inguinal  canal  in  the 
former.  In  women,  owing  to  its  small  size,  the  inguinal  canal  can 
only  be  satisfactorily  examined  when  there  is  an  inguinal  hernia.  In 
irreducible  herniae  we  must  depend  upon  the  position  of  the  hernia  rela- 
tive to  Poupart's  ligament  and  the  pubic  spine,  a  femoral  hernia  being 
altogether  below  the  former  and  external  to  the  latter.  In  fat  subjects 
we  may  not  be  able  to  feel  Poupart's  ligament  even  in  its  inner  half, 
but  the  furrow  of  the  groin  nearly  corresponds  to  it,  or  we  may  draw 
a  line  between  its  bony  attachments,  finding  the  pubic  spine  in  males 
by  invaginating  the  scrotum. 

So-called  hernia  adiposa  is  not  a  real  hernia  but,  from  its  position 
and  form,  it  may  give  difficulty  in  diagnosis  here  as  with  other  forms  of 
hernia.  It  is  a  lipjoma  of  the  suhperitoneaJ  tissue  which  in  its  growth 
takes  the  same  course  as  a  hernia.  It  is  irreducible  and  tends  to  draw 
the  peritoneum  after  it,  thus  forming  a  pouch  which  may  be  the  start- 
ing point  of  a  true  hernia. 

Irregular  and  rare  forms  of  femoral  hernia  may  occur  :  (1)  To 
the  outer  side  of  the  artery  ;  (2)  hourglass-shaped  hernia  due  to  the 
escape  of  a  part  of  the  hernia  through  a  rent  in  one  of  the  covering 
layers,  generally  the  cribriform  fascia ;  (3)  within  the  proper  sheath 
of  the  vessels,  etc. 

POSTERIOR   ABDOMINAL    WALL. 

Iliac  Region. 

This  region,  the  lowest  part  of  the  posterior  abdominal  wall,  corre- 
sponds to  the  iliac  fossa  and  is  bounded  below  by  Poupart's  ligament, 
internally  by  the  pelvic  brim  (iliopectineal  line),  above  and  externally 
by  the  iliac  crest.  The  right  and  left  iliac  fossae  are  separated  from 
each  other  by  the  pelvic  cavity.  It  is  comparatively  small  in  children 
and  attains  its  size  about  the  time  of  puberty.  It  can  be  examined 
only  through  the  abdominal  wall  which  should  be  relaxed  by  flexion 
of  the  thigh. 


LAYERS  OF  THE  ILIAC  REGION.  276 

In  studying  this  region  layer  Ijy  layer  from  before  backwards,  we 
notice  : 

1.  Parietal  Peritoneum. — This  becomes  continuous  with  that  lining 
the  antero-lateral  abdominal  wall  along  the  iliac  crest  and  Poupart's 
ligament,  where  it  is  loosely  attached  by  means  of  the  next  layer  so  as 
to  be  easily  rnl.srd  up. 

2.  The  subperitoneal  tissue  is  here  very  abunfJont  and  loose,  and 
contains  more  or  kss  I'at.  It  is  continuous  with  the  like  layer  in  the 
neighboring  regions  of  the  abdominal  parietes,  the  antero-lateral  re- 
gion below  and  externally,  the  lumbar  above  and  the  pelvis  internally 
(the  latter  including  the  tissue  between  the  folds  of  the  broad  liga- 
ments in  the  female). 

Its  loose aeas  favors  tlie  spread  of  abscess.  Such  an  abscess  may  ori- 
ginate in  a  viscus  which  occupies  this  region,  the  cfecum  or  appendix 
on  the  right,  the  sigmoid  flexure  on  the  left.  The  infection  may 
reach  this  layer  by  passing  along  the  lymphatics  or  the  tissue  lying 
between  the  layers  of  peritoneum  which  attach  the  viscus.  On  the 
other  hand  an  al)scess  in  this  tissue  may  perforate  and  discharge  into 
one  of  these  viscera.  Again  such  an  abscess  may  sink  down  from  the 
lumbar  region  or  rise  up  from  the  pelvis,  as  in  cases  of  retroperitoneal 
pelvic  abscess  or  pelvic  cellulitis  in  the  female. 

Abscess  in  this  tissue  is  more  common  on  the  right  side  owing  to  the 
presence  of  the  appendix.  As  a  rule  it  sinks  to  the  level  of  Poupart's 
lifjanwut  and  here  it  collects  and  displaces  upward  the  peritoneum 
from  the  iliac  fa.scia  behind  and  the  transversalis  fascia  in  front  and 
"points  "  above  Poupart's  ligament.  In  this  position  it  may  be  opened 
by  incising  the  transversalis  fascia  and  the  overlying  layers  without 
opening  the  peritoneum  which  is  displaced  upward.  This  was  the 
course  of  many  abscesses  originating  in  the  apendix,  the  so-called 
perityphlitic  abscesses,  before  the  adoption  of  the  modern  operation  for 
appendicitis. 

Many  cases  of  abscess  resulting  from  pelvic  cellulitis  open  or  are 
opened  here.  Occasionally  pus  collecting  here  escapes  into  the  upper 
and  inner  aspect  of  the  thigh  through  the  femoral  ring  or  along  the 
iliac  vessels,  which  lie  in  this  layer,  or  it  may  sink  into  the  j)elvis. 

Structures  in  the  Subperitoneal  Layer.  —  The  external  iliac 
artery  and  vein,  speniiatic  or  ovarian  vessels,  genitocrural  nerves, 
ureter  and  vas  deferens. 

External  Iliac  Vessels. — The  course  of  the  artery  is  represented  by 
a  line,  curved  slightly  outward,  from  a  point  half  an  inch  to  the  left 
and  below  the  umbilicus  and  directed  downward  and  outward  to 
Poupart's  ligament,  a  little  internal  to  its  center,  or  half  way  between 
the  anterior  superior  iliac  spine  and  the  symphysis  pubis.  The  upper 
tiro  inches  of  this  line  would  represent  the  common  iliac  artery,  the 
lower  two  thirds  or  the  part  below  the  level  of  the  lumbosacral 
junction  the  external  iliac. 

The  vein  lies  to  its  inner  side,  inclining  behind  it  above  on  the 
right  side  so  as  to  reach  the  outside  of  the  right  common  iliac  artery. 


276  THE  ABDOMEN. 

Position. — These  vessels  lie  upon  the  inner  border  of  the  psoas 
muscle  along  the  brira  of  the  pelvis  in  the  fibrocellular  sheath,  con- 
nected with  the  iliac  fascia  which  separates  it  from  the  muscle. 

Relations. — The  external  iliac  vessels  are  crossed  in  front  hy  the 
sigmoid  flexure  on  the  left  and  the  end  of  the  ileum  on  the  right  side. 
The  ureter  sometimes  crosses  over  their  upper  end  instead  of  over  the 
bifurcation  of  the  common  iliac  vessels.  The  spermatic  vessels  and 
the  genital  branch  of  the  genitocrural  nerve  lie  upon  the  lower  part  of 
the  artery  for  a  short  distance,  and  the  deep  circumflex  iliac  vein 
crosses  it  just  above  its  lower  limit.  The  vas  deferens  in  the  male, 
and  the  round  ligament  and  ovarian  vessels  in  the  female,  cross  it  to 
reach  the  pelvis.  The  crural  branch  of  the  genitocrural  nerve  descends 
in  front  of  the  artery. 

These  relations  should  be  borne  in  mind  in  ligature  of  the  external 
iliac  artery.  In  this  operation,  whose  principal  indication  is  femoral 
aneurism,  the  most  important  relations  are  those  of  the  vein,  for  the 
ligature  is  passed  from  the  venous  side,  and  the  relations  to  the  loose 
subperitoneal  tissue,  for  the  latter  allows  the  exposure  of  the  vessel  by 
permitting  the  raising  up  of  the  peritoneum  from  the  iliac  fossa  through 
an  incision  along  the  lower  or  outer  border  of  the  region. 

The  incision  may  be  made  :  (1)  slightly  above  and  parallel  with  the 
outer  half  of  Poupart^s  ligament ;  or  (2)  parallel  with  and  over  the  course 
of  the  artery,  a  little  external  to  the  course  of  the  deep  epigastric  so  as 
to  avoid  the  latter,  and  commencing  a  little  above  Poupart's  ligament. 

In  (1)  we  incise  through  the  external  oblique  aponeurosis  and  then, 
retracting  upward  the  outer  end  of  the  free  edge  of  the  conjoined 
tendon  at  the  inner  angle  of  the  wound,  w'e  may  incise  the  latter  along 
its  attachment  to  the  outer  half  of  Poupart's  ligament,  to  gain  room. 
Then  incising  in  the  same  line  the  transversalis  fascia,  we  expose  the 
loose  subperitoneal  tissue,  in  which  the  artery  lies  in  front  of  the  iliac 
fascia.  In  this  tissue  at  the  inner  angle  of  the  incision  wc  may  expose 
the  deep  epigastric  artery,  which  should  be  retracted  upward  and 
inward.  The  peritoneum  is  then  bluntly  detached  from  the  iliac 
fossa,  from  its  reflection  behind  Poupart's  ligament  upward  and 
inward  to  the  inner  border  of  the  psoas,  which  forms  a  convenient 
landmark  for  the  artery. 

There  is  clanr/er  of  wounding  the  deep  circumflex  iliac  vessels  by 
incising  too  close  to  Poupart's  ligament  and  of  wounding  the  deep 
epigastric  vessels  by  incising  too  far  internally.  Mesially  the  incision 
is  not  commonly  carried  beyond  the  level  of  the  internal  abdominal 
ring,  as  that  is  slightly  internal  to  the  middle  of  Poupart's  ligament, 
but  even  if  it  should  be  there  is  half  an  inch  between  the  ligament 
and  the  ring,  so  that  the  latter  need  not  be  injured  unless  the  incision 
is  too  high. 

After  separating  the  artery  from  the  vein,  through  the  loose  tissue 
which  forms  a  kind  of  sheath  for  it,  the  artery  is  tied  about  1^  inches 
above  Poupart's  ligament  to  avoid  the  proximity  of  collateral  branches 
and  important  relations.   The  operator  should  avoid  including  the  crural 


THE   ILIAC  FASCIA.  277 

branch  of  the  genitocrural  nerve  hi  tlie  In/ature  which  \s  pa^f<ed  from 
witliin  outwards. 

In  (2),  the  principle  is  the  same,  namely  bluntly  detaching  the  peri- 
toneum from  the  iliac  fossa  from  its  reflection  behind  Poupart's  liga- 
ment in  an  upward  and  inward  direction.  The  artery  is  exposed  at 
greater  depth  and  there  is  more  danger  of  hernia,  l>ut  the  deep  epi- 
gastric and  circumflex  iliac  vessels  and  the  internal  ring  are  in  no 
danger.  The  artery  may  also  be  tied  higher  up  and  the  skin  incision 
is  further  from  the  groin  in  case  an  aneurism  bulges  there. 

At  the  j)re.sent  day  the  Iniiisprritoiu'dl  method  is  more  often  employed 
than  formerly,  and  this  allows  of  ligature  high  up  or  of  ligature  of  the 
common  iliac,  if  necessary.  The  chief  objections  are  those  common  to 
abdominal  incisions  in  the  semilunar  line  (see  p.  253),  unless  the  in- 
termuscular method  is  used. 

The  common  iliac  artery  may  be  reached  and  tied  extraperitoneal ly 
by  an  extension  of  the  incision  (1)  for  the  external  iliac  upward  toward 
the  lower  ribs,  or  upward  and  inward  toward  the  umbilicus.  This  opera- 
tion is  very  rarely  called  for.  I  have  found  McBurney's  suggestion, 
the  compression  of  the  common  iliac  by  the  finger  of  an  assistant  intro- 
duced through  an  oblique  intermuscular  abdominal  incision,  most  effi- 
cient and  useful  in  amputation  at  the  hip  joint. 

The  collateral  circulation  after  ligation  of  the  external  iliac  artery  is 
derived  from  the  umistomosiH  of  the  deep  epigastric  with  the  internal 
mammary,  obturator,  lumbar  and  lower  intercostals  ;  of  the  deep  cir- 
cumflex iliac  with  the  iliolumbar  ;  of  the  internal  circumflex  with  the 
obturator  ;  of  the  external  circumflex  with  the  gluteal ;  of  the  external 
pudic  with  the  internal  pudic,  and  other  minor  anastomoses. 

The  external  iliac  lymphatic  nodes  extend  in  a  chain  of  about  five 
along  the  anterior  and  inner  aspect  of  the  external  iliac  vessels.  As 
they  receive  the  lymphatics  from  the  inguinal  nodes  and  the  vessels 
accompanying  the  deep  epigastric  and  deep  circumflex  iliac  arteries 
they  may  be  enlarged  from  infection  from  these  sources.  We  may  [xd- 
pate  them,  when  enlarged,  through  the  abdomen,  except  in  very  fat  sub- 
jects, and  so  determine  the  extent  of  the  lymphatic  infection  in  septic 
or  cancerous  cases.  These  nodes  when  enlarged  may  cause  persistent 
cedcmd  of  the  lower  extremity   by  pressure  on  the  external   iliac  vein. 

The  iliac  fascia  covers  the  iliopsoas  muscle  and  is  attached  to 
bone  and  fascia  around  the  limits  of  this  muscle,  thus  forming  for  it  a 
single  osseo-fibrous  compartment.  At  the  most  dependent  part  the 
muscle  and  fascia  pass  into  the  thigh.  The  ujipcr  part  sheaths 
the  ui)])er  part  of  the  psoas  and  is  thin  and  adherent  to  it.  It 
ends  above  at  the  diaphragm  in  a  thickening,  the  ligamentum 
arcuatum  internum,  and  is  attached,  along  the  outer  border  of  the 
psoas,  to  the  anterior  layer  of  the  lumbar  fascia.  Tiie  loinr  jxirf,  cov- 
ering the  iliacus  and  the  lower  part  of  the  psoas,  is  thicker  and  separated 
from  tiie  muscle  by  a  thin  lai/cr  of  fatti/  connn'tivc  fi.^sav  which  favors 
the  formation  or  spread  of  pus.  In  this  loose  tissue  lie  the  anterior 
crura!    and    external   cutaneous  nerves,  and    some  muscular  arterial 


278  THE  ABDOMEN. 

branches.  The  large  vessels  are  therefore  separated  by  the  iliac  fascia 
from  the  principal  nerves  of  this  region,  save  the  genitocrnral.  The 
lower  part  of  the  fascia  is  attached  to  the  iliac  crest  externally  and 
above,  to  the  iliopectineal  line  internally,  while  inferiorly  it  is  adherent 
to  the  outer  4  cm,  of  Poupart's  ligament  and  continues  under  the 
latter  into  the  thigh  as  the  sheath  of  the  muscle  as  far  as  its  insertion. 
Internal  to  the  muscle  it  passes  into  the  thigh  behind  the  vessels,  whose 
sheath  it  helps  to  form,  and  is  conti)tuous  icitJi  the  fascia  covering  the 
pectineus,  /.  e.,  the  pectineal  fascia  or  the  pubic  portion  of  the  fascia 
lata.  Between  the  iliopsoas  and  the  pectineus  it  sends  back  a  fibrous 
'partition  to  the  pectineal  eminence  and  the  capside  of  the  hip. 

Although  in  surgery  we  find  that  abscesses  do  not  always  respect 
fibrous  fascial  planes,  but  sometimes  break  through  them,  this  is  less 
true  of  those  beneath  the  iliac  fascia,  especially  in  the  case  of  "  cold  " 
or  tubercular  abscesses. 

Abscesses  beneath  the  iliac  fasciaare  often  known  as  "psoas  abscesses'' 
and  have  a  quite  definite  course.  They  sink  by  gravity  along  the  course 
of  the  muscle,  pass  under  the  outer  half  of  Poupart's  ligament  and 
point  at  the  upper  and  anterior  part  of  the  thigh,  external  to  the  large 
vessels,  where  they  may  be  safely  opened.  Occasionally  they  do  not 
take  this  course,  but  may  point  elsewhere  after  breaking  through  the 
fascia.  They  may  extend  into  the  lumbar  region,  over  the  iliac  crest 
into  the  gluteal  region,  over  the  pelvic  brim  into  the  pelvis,  or  along 
the  inguinal  canal  into  the  scrotum  and  find  an  exit  in  the  parts 
named.  They  may  also  open  above  instead  of  below  the  fold  of  the 
groin.  In  other  cases  I  have  seen  a  psoas  abscess  pass  lower  into  the 
thigh,  probably  following  branches  of  the  anterior  crural  nerve  where 
they  pierce  the  sheath  of  the  iliopsoas. 

We  call  these  abscesses  "psoas  abscesses''  because  most  of  them  are 
due  to  spinal  caries  and  make  their  way  first  into  the  sheath  of  the 
psoas.  If  the  caries  is  in  the  lumbar  spine  direct  extension  into  the 
psoas  muscle  readily  occurs.  The  lumbar  curve  is  likely  to  be  flat- 
tened out  in  such  cases.  Instead  of  entering  the  ])soas  sheath  such 
abscesses  may  pass  behind  it  and  enter  and  point  in  the  lumbar  region, 
or  they  may  extend  between  the  muscular  and  fascial  planes  of  the  an- 
terior belly  wall.  If  the  caries  is  in  the  thoracic  rertebra^  the  pus  de- 
scends by  gravity  in  the  posterior  mediastinum  along  the  front  of  the 
spinal  column  to  the  upper  end  of  the  psoas.  This  it  penetrates,  like  a 
wedge,  between  its  upper  origins,  /.  e.,  from  the  body  and  the  transverse 
process  of  the  first  lumbar  vertebra,  at  the  same  time  passing  under 
the  ligamentum  arcuatum  internum.  The  pus  more  or  less  entirely 
destroys  the  muscle,  leaving  the  lumbar  nerves  free  in  a  pus  sac. 

In  inflammation  of  the  iliopsoas,  or  in  psoas  abscess  before  the  pus 
is  evacuated,  the  thif/h  is  kept  flexed,  for  in  this  position  the  muscle  is 
most  relaxed,  the  abscess  is  least  tense,  and  the  lumbar  nerves  less 
compressed  and  irritated.  This  relaxation  is  due  to  the  fact  that  flexion 
of  the  thigh  is  the  principal  action  of  the  iliopsoas  ;  the  outward  rota- 
tion, sometimes  associated  with  it,  is  due  to  other  causes,  for  the  ilio- 


LUMBAR  REGION.  279 

psoas  is  not  an  outward  rotator.  According  to  Hyrtl  the  iliopsoas  can- 
not alone,  or  even  with  the  poctineus,  flex  the  thi<;h,  so  that  in  high 
amputation  of  the  thigh  the  patient  cannot  flex  tlie  stump  until  the 
other  flexors  have  become  adherent  to  the  scar  or  to  the  bone. 

Abscess  similar  in  course  to  the  foregoing  may  arise  in  the  iliac  fossa 
which  might  properly  be  called  "  iliac  abscess,''  but  this  term  is  more 
often  applied  to  those  in  the  iliac  subperitoneal  tissue. 

In  psoas  ai)scesses  the  fold  of  the  groin  is  partly  effaced  in  its  outer 
part,  fluctuation  may  be  obtained  below  Poupart's  ligament  and  a  full- 
ness is  felt  in  the  iliac  fossa  or,  in  thin  patients,  along  the  course  of 
the  psoas. 

From  the  above  we  see  that  tNso  well-marked  forms  of  abscess  occur 
in  the  iliac  region,  (1)  in  the  subperitoneal  tissue  and  (2)  beneath  the 
iliac  fascia,  separated  as  to  their  position  by  the  iliac  fascia. 

The  ilium,  forming  the  iliac  fossa,  separates  this  region  from  the 
gluteal  region  behind,  hence  pus  in  this  region  sometimes  gains  access 
to  the  gluteal  region  by  a  perforation  of  the  thin  translucent  bone. 
The  posterior  drainage  of  some  cases  of  abscess  in  the  iliac  fossa, 
through  a  trephine  opening  in  the  bone,  has  been  advised  and  prac- 
tised, according  to  the  principle  of  drainage  at  the  most  dependent 
point,  /.  e.,  in  the  supine  position. 

Tumors,  especially  enchondroma  and  osteo-euchondroma,  occasionally 
take  origin  from  the  iliac  bone  or  its  periosteum.  Fracture  from  direct 
violence  may  involve  almost  any  part  of  the  ilium,  the  fossa,  the 
superior  spine  or  the  crest.  The  latter  may  be  separated  entire  as  an 
epiphysis  previous  to  about  the  twenty-fourth  year,  when  it  joins  the 
bone.  In  fractures  through  the  fossa  the  fragments  are  usually  held 
in  position  by  the  muscles  attached  on  either  side,  which  act  as  splints. 
Owing  to  the  many  muscular  attachments,  absolute  rest  is  required  in 
the  treatment  of  fractures  of  the  ilium. 

Lumbar   Region. 

The  two  lumbar  regions,  right  and  left,  adjoin  one  another  in  the 
median  liiie  and  are  bounded  above  by  the  twelfth  ribs  ;  below  by  the 
posterior  half  of  the  iliac  crests  ;  and  laterally  by  the  external  border 
of  the  external  abdominal  oblique  muscles. 

Superficial  View  from  he/iin<L  In  the  median  line  we  see  a  ver- 
tical groove,  the  sjjiiii(/  fnrroir^  which  is  due  to  the  prominence  of  the 
erector  spinae  mass  on  either  side  and  to  the  attachment  of  the  skin,  by 
means  of  the  subcutaneous  tissue,  to  the  tips  of  the  lumbar  spinous 
processes,  which  we  feel  in  the  bottom  of  the  groove.  The  spinal  furrow 
spreads  out  below  into  the  angular  interval  l)etween  the  gluteal  muscles. 
The  lateral  margins  of  the  erector  spinie  muscle  can  be  felt  and  usually 
seen,  except  in  fat  subjects.  Lateral  to  the  erector  spinse  mass  the 
surface  is  flattened.  The  backward  projection  of  one  or  more  of  the 
spines  indicates  an  injury  or  a  disease,  probably  caries  of  tiie  bodies 
of  the  corresponding  vertebrae. 


280  THE  ABDOMEN. 

Normally  the  line  of  the  lumbar  spines  and  the  contour  of  the 
lumbar  region  is  vertically  concave,  and  slightly  more  so  in  women 
then  in  men.  In  hip  Joint  disease,  when  the  joint  is  anchylosed  in  the 
flexed  position,  this  concavity  is  much  increased  by  extending  the 
thigh,  giving  rise  to  the  deformity  known  as  lordosis,  and  it  is  flat- 
tened out  on  flexing  the  thigh  beyond  the  angle  at  which  it  is  an- 
chylosed. These  are  important  diagnostic  points,  and  are  due  to 
the  very  free  flexion  and  extension  in  the  lumbar  vertebrae,  which  tilt 
the  pelvis  and  take  the  place  of  the  similar  movements  in  the  hip. 

A  horizontal  line  connecting  the  highest  points  of  the  iliac  crests 
corresponds  to  the  spine  of  the  fourth  lumbar  vertebra.  In  the  inter- 
space above  (or  below)  this  spine  lumbar  puncture  is  practised,  one  fifth 
to  two  fifths  of  an  inch  from  the  median  line.  This  is  below  the  spinal 
cord,  which  reaches  to  the  top  of  the  second  lumbar  vertebra. 

The  subcutaneous  tissue  is  a  thick  dense  layer  containing  but 
little  fat  and  connected  closely  with  the  skin  but  only  loosely  with 
the  fascia  beneath,  thus  allowing  large  extravasations  of  blood  or  of  a 
sero-sanguineous  fluid  from  glancing  blows. 

Superficial  Muscles. — The  latissimus  dorsi,  like  the  external  ab- 
dominal oblique,  is  attached  to  the  outer  lip  of  the  iliac  crest.  At  the 
mid  point  of  the  crest  an  interval  between  these  two  muscles  usually 
exists,  which  is  triangular  in  shape  owing  to  their  converging  above. 
This  triangle,  with  its  base  below,  is  known  as  the  triangle  of  Petit  and 
is  a  weak  spot  representing  a  lack  of  one  of  the  muscular  layers. 
Hence  it  is  that  a  rare  form  of  hernia,  lumbar  hernia,  occurs  here  and 
it  is  a  favorite  spot  for  the  pointing  of  lumbar  abscesses.  Its  floor  is 
formed  by  the  internal  oblique  muscle,  which  overlaps  the  external 
oblique  posteriorly  and  thus  comes  in  contact  with  the  subcutaneous 
tissue  in  this  small  triangular  area. 

Both  the  internal  oblique  and  the  latissimus  dorsi  are  attached  to  the 
dense  posterior  layer  of  the  lumbar  fascia.     (Fig.  70.) 

The  lumbar  fascia,  the  j^osterior,  middle,  and  anterior  layers  of  this 
fascia  are  attached  mesially  to  the  tips  of  the  lumbar  spines,  the  tips 
of  the  lumbar  transverse  processes  and  the  front  of  the  bases  of  the 
latter  respectively.  Laterally  they  join  together  and  thus  sheath  and 
form  an  osseofibrous  compartment  for  the  two  vertical  muscles  of  this 
region,  the  erector  spinje  and  the  quadratus  lumborum. 

The  posterior  joins  the  middle  layer  of  the  fascia  at  the  outer  border 
of  the  erector  spinse.  The  middle  layer,  thus  reinforced,  joins  the 
anterior  layer  of  the  fascia  at  the  outer  border  of  the  quadratus 
lumborum.  The  combination  of  these  three  layers,  about  three  inches 
from  the  tips  of  the  lumbar  transverse  processes,  forms  a  fascia  which 
gives  origin  to  the  transversalis  muscle  and  hence  is  called  the  posterior 
aponeurosis  of  the  transversalis  muscle,  a  name  sometimes  applied  to  the 
entire  fascia.  The  posterior  layer  forms  a  part  of  the  thick  vertebral 
aponeurosis  covering  the  muscles  of  the  back. 

The  posterior  and  middle  layers,  where  they  form  the  sheath  of  the 
erector  spinse,  are  very  thick  and  strong,  hence  abscesses  seldom  if  ever 


PLATE   XXXIV. 


FIG.  70. 


COMPARTMENT     OF 

QUADBATUS 

LUMBORUM 


ANSVERSA- 
IS    MUSCLE 

INT.    OBLIQUE    MUSC. 
EXT.  OBLIQUE  MUSC. 


Transverse  section  at  level  ol"  the  second  lumbar  vertebra, 
to  show  the  position  of  the  kidney,  the  lumbar  fascia,  and 
the  posterior  attachment  of  the  abdominal  muscles  (the 
external    oblique    is    drawn    too    near    tiie    median    line). 


MUSCLES  OF  THE  LUMBAR  REGION.  281 

penetrate  the  erector  spinae  muscle  unless  they  originate  in  the  bones  of 
the  neural  arch  with  which  the  muscle  is  in  contact.  On  the  other 
hand  the  (inferior  layer,  covering  the  front  of  the  quadratus  lumborum, 
is  very  thin  and  is  in  contact  witli  tiie  sul)peritoncal  connective  tissue 
and  fat  in  relation  witii  the  kidney  and  colon. 

The  lumbar  fascia  is  very  variously  described.  Some  (Joessel) 
describe  two  layers,  a  snj)orficial  or  ])ostcrior,  and  a  deep  layer,  the 
third  or  anterior  layer  being  called  the  transversalis  fascia.  Others 
(Gray)  describing  three  layers  as  we  have  done  above,  si)cak  of  the 
anterior  layer  as  identical  with  the  transversalis  fascia.  Others  again 
(Morris)  describe  the  transversalis  fascia  as  ending  laterally  in  the  loose 
fat  behind  the  kidney  while  the  three  layers  of  the  lumbar  fascia  are 
described  as  above.  Tillaux  describes  two  layers  and  a  division  of  the 
posterior  layer  so  as  to  invest  the  erector  spinse  mass.  The  term 
lumbar  fascia  or  aponeurosis  he  applies  only  to  the  layer  behind  the 
erector  spiuje. 

On  the  whole  the  weight  of  authority  makes  the  transversalis  fascia 
continuous  with  the  anterior  layer  of  the  lumbar  fascia;  the  other 
differences  of  description  are  of  no  practical  importance.  The  impor- 
tant point  is  that  we  have  three  fascial  layers,  forming  two  muscular 
sheaths,  continuous  with  the  posterior  aponeurotic  attachment  of  the 
transversalis  muscle,  giving  attachment  to  other  muscles  and  directing 
the  course  of  abscess,  etc. 

Abscess  starting  in  the  lumbar  subperitoneal  tissue  may  readily  per- 
forate the  anterior  fascial  layer,  enter  and  pass  through  the  thin  quad- 
ratus  muscle,  and  perforate  its  posterior  sheath  external  to  the  outer 
border  of  the  erector  spinse.  Or  it  may  perforate  the  posterior  apo- 
neurosis of  the  transversalis  external  to  the  quadratus  muscle.  In 
certain  cases  this  may  be  facilitated  by  the  abscess  following  the  last 
thoracic  or  the  iliohy])()gastric  nerves  where  they  pierce  this  aponeu- 
rosis, below  the  last  rib  and  above  the  iliac  crest  respectively.  In 
either  case  the  abscess  comes  to  lie  under  the  internal  oblique  and  its 
posterior  aponeurotic  attachment.  The  common  course  is  then  to  per- 
forate the  latter  and  sink  to  the  triangle  of  Petit  or  to  the  outer 
border  of  the  erector  s)Mn;e,  where  it  appears  as  a  lumbar  abscess. 

Muscles. — The  thick  erector  spinas  has  a  dense  fascial  sheath  which 
we  avoid  opening  in  lumbar  incisions,  for  little  or  no  room  is  thereby 
gained  and  we  thus  avoid  the  danger  of  suj^jniration  within  the 
sheath.  The  erector  spinie  mass  occupies  the  entire  vert.bral  groove  on 
each  side  and  ])ro)ects  beyond  it  laterally.  It  forms  a  marked  projec- 
tion on  each  side  of  the  median  line,  which  thus  ])resents  a  furrow.  Its 
outer  border,  limited  by  the  union  of  the  posterior  and  middle  layei-s 
of  the  lumbar  fascia,  is  readily  felt  and  forms  an  excellent  landmark 
in  makint:  transverse  lumbar  incisions. 

The  thin  flat  quadratus  lumborum  is  one  third  broader  than  the 
erector  spina?  and  thus  extends  beyond  it  laterally,  where  it  is  itself 
overlapi)ed  by  the  internal  obli(|Ue.  The  outer  third  of  the  thin  quad- 
ratus muscle,  unsupported  by  the  erector  spinas  offers  less  resistance  to 


282  THE  ABDOMEN. 

protrusions  from  within  than  the  inner  two  thirds.  The  outer  border 
of  the  quadratus  lumboriun  forms  the  most  valuable  landmark  in  lum- 
bar operations.  This  border  is  not  vertical  but  inclines  inivard  as  it 
passes  upward.  Just  above  the  iliac  crest  it  corresponds  to  a  line 
drawn  vertically  from  the  middle  of  the  crest,  hence  it  corresponds  to 
the  position  of  Petit's  triangle.  Midway  between  the  crest  and  the 
last  ril)  it  may  be  about  an  inch  internal  to  the  above  line. 

Incisions. — Vertical  lumbar  incisions  are  made  from  a  point  one  half 
to  one  inch  mesial  to  the  middle  of  the  iliac  crest,  so  as  to  meet  the 
outer  border  of  the  quadratus  about  the  middle  of  the  lumbar  region. 
This  line  of  incision  also  corresponds  to  the  course  of  the  colon.  This 
vertical  incision  is  objectionable  because  it  divides  the  lumbar  and 
last  thoracic  vessels  and  nerves,  which  cross  its  course,  and  it  affords 
comparatively  little  room.  Hence  an  oblique  incision,  commencing  in 
the  costo-vertebral  angle  not  far  internal  to  the  outer  border  of  the 
erector  spinge,  is  preferable  as  it  parallels  the  vessels,  the  nerves  and  the 
natural  creases  and  cleavage  lines  of  the  skin  of  this  region.  If,  as  is 
often  done,  we  incise  just  below  the  twelfth  rib  the  latter  should  be 
determined  by  counting  from  above,  for  Dr.  HoU  has  shown  that  the 
rib  is  frequently  rudimentary  and  so  short  as  not  to  reach  beyond  the 
erector  spinie  mass,  so  as  to  be  mistaken  for  a  lumbar  transverse 
process.  If  the  incision  should  then  be  made  just  below  the  eleventh 
rib  the  p/e;t/'a  would  be  in  danger  of  being  opened,  an  accident  that 
has  been  recorded  by  Professor  Dumreicher  of  Vienna  and  others.  In 
these  cases  the  lower  edge  of  the  pleura  extends  from  the  lower  border 
of  the  last  thoracic  vertebra  nearly  horizontally  to  the  lower  border  of 
the  eleventh  rib.  Exceptionally  also  the  pleura  may  project  consider- 
ably below  a  normal  twelfth  rib,  so  as  to  require  caution  in  any  case 
at  the  inner  and  upper  angle  of  the  incision.  The  fact  that  we  may 
have  a  correspondingly  high  level  of  the  ])leura  with  a  rudimentary 
twelfth  rib  makes  the  above  caution  no  less  imperative  in  all  cases. 

The  oblique  incisions  extend  laterally  a  variable  distance  beyond  the 
lumbar  region,  and  divide  in  the  superficial  muscular  layer,  the  latis- 
simus  dorsi  and  the  external  oblique  ;  in  the  next  deeper  layer  the 
internal  oblique  and  its  posterior  aponeurosis ;  and  beneath  this  the 
transversalis  and  its  posterior  aponeurosis,  including  that  part  of  it 
forming  the  dorsal  layer  of  the  sheath  of  the  quadratus  muscle.  Re- 
tracting the  outer  border  of  the  latter  muscle  inwards,  or  incising  it  if 
necessary  to  gain  more  room,  we  incise  its  anterior  fascial  covering, 
and  the  transversalis  fascia  continuous  with  it,  and  reach  the  •'sub- 
peritoneal conncctice  tissue  in  relation  to  the  kidney  and  colon.  It  is 
in  this  tissue,  which  here  contains  much  fat,  that  perlnephritic  abscess 
develops.  We  have  shown  above  its  most  common  course  (lumbar 
abscess,  p.  281)  but  it  may  also  sink  in  the  subperitoneal  tissue  into  the 
iliac  fossa  or  pelvis,  and  not  infrequently  it  burrows  through  the  dia- 
phragm and  parietal  pleura  and  so  enters  the  pleural  cavity  (p.  212). 

The  vessels  are  the  subcostal  (twelfth  or  last  thoracic),  and  the 
four  lumbar  arteries  and  their  accompanying  veins.     Of  these  the  sub- 


NERVES  OF  THE  LUMBAR  REGION.  283 

costal  and  first  lumbar,  and  sometimes  the  last  liiml)ar,  pass  outward 
in  front  of  the  quadratus  lumhorum,  and  Ijchind  the  anterior  layer  of 
the  fascia,  the  otliers  lie  behind  the  (juadratus.  Beyond  the  hiteral 
border  of  this  muscle  they  pass  forward  l)etween  the  muscular  layers 
of  the  anterior  abdominal  wall  and  anastomose  with  the  vessels  found 
there,  as  well  as  with  those  above  and  below.  The  veins  on  either 
side  are  connected  l)y  a  vertical  trunk,  the  aHcoidiiifj  hrrahnr  rein  wiiicb, 
continued  into  the  azygos  vein  of  eacii  side,  furnisiies  an  anastomotic 
course  in  case  of  obstruction  of  tlie  inferior  cava. 

Lymphatics. — The  superficial  vessels  empty  into  the  inguinal  nodes, 
the  deep  ]ynn)liatics  accomjiany  the  blood  vessels  and  empty  into  the 
lumbar  nodes  along  the  alxlominal  aorta. 

Nerves. — Tlie  twelfth  thoracic  and  tiie  iliohypogastric  and  ilioin- 
guinal branches  of  the  first  lumbar  nerves  lie  in  front  of  the  quad- 
ratus lumborum  and  behind  the  anterior  layer  of  its  sheath  ;  the  first 
named  a  little  below  and  ])arallel  with  the  twelftii  rib,  the  others 
nearly  parallel  with  it  and  successively  lower.  The  three  nerves  just 
named  pass  behind  the  kidney  obliquely  from  wathin  and  above,  out- 
ward and  downward.  Pressure  upon  them  by  a  perinephritic  abscess 
or  a  large  tumor  of  the  kidney  may  give  rise  to  pain  in  the  areas  of 
their  distribution.  Thus  in  a  case  of  perinephritic  abscess  I  have  seen 
the  principal  pain  in  the  lateral  gluteal  region  and  over  the  outside  of 
the  hip  which  are  supplied  respectively  by  the  large  lateral  cutaneous 
branches  of  the  last  thoracic  and  the  iliohypogastric  nerves.  The 
same  renal  lesions  may  cause  fcvion  of  the  thif/h  from  })ressure  on  the 
branches  of  the  second  and  third  lumbar  nerves  supplying  the  iliopsoas 
and  pectineus  muscles. 

The  obliquely  transverse  direction  of  the  vessels  and  nerves  of  this 
region  renders  them  liable  to  division  by  a  vertical  lumbar  incision, 
but  not  by  an  obliquely  transverse  one,  a  point  of  superiority  of  the 
latter  incision.  The  small  size  of  the  vessels  renders  their  division 
comparatively  unimportant. 

Lumbago  is  a  painful  affection  of  the  lumbar  region  depending 
upon  several  different  causes.  It  may  be  due  to  a  strain  of  the  mus- 
cular or  fibrous  tissues  of  the  region,  from  a  violent  exertion  ;  to 
muscular  rheumatism  ;  or  to  a  neuralgia  or  a  neuritis  of  the  nerves, 
giving  rise  to  painful  areas  in  the  distribution  of  the  nerves.  Sj/mpa- 
thetic  Jiiinlxic/o  may  be  due  to  a  variety  of  causes  ;  disease  of  the  ver- 
tebra?, spinal  cord,  kidney  and  urinary  apparatus,  or  infectious  fevers 
(grippe,  smallpox,  etc.). 

Wounds  of  the  region  are  rare,  and  are  likely  to  be  .serious  oidy 
when  lateral  to  the  erector  spina?  mass,  where  the  abdominal  wall  is 
thinner.  Contusions  may  cause  an  injury  to  the  viscera  (kidney  most 
often,  possibly  also  the  colon)  without  any  appreciable  sign  of  injury 
superficially. 

In  the  reclining  position  the  peritoneal  aspect  of  the  lumbar  region 
is  on  a  lower  level  than  that  of  the  iliac  fi)ssa,  hence  pus  or  other  fiuid, 
if  free  in  the  latter  region,  tends  to  gravitate  to  the  former.      This   is 


284  THE  ABDOMEN. 

to  be  carefully  borne  in  mind  in  operating  for  appendicitis  and  this 
course,  which  may  be  taken  by  pus  external  to  the  cjecum  and  colon, 
should  be  closed  by  gauze  packing. 

THE  ABDOMINAL  CAVITY. 

T\\Q  form  of  the  cavity  is  that  of  an  oval  with  its  larger  end  above. 
Owing  to  the  obliquity  of  the  diaphragm,  the  main  axis  of  the  cavity 
is  oblique  from  above  downward,  forward  and  to  the  right,  and  is 
directed  to  the  right  pubic  spine.  This  is  given  as  one  reason  for  the 
greater  frequency  of  hernia  on  the  right  ride.  The  obliquity  of  the 
axis  of  the  pelvis  is  from  above  downward  and  backward,  so  that  in 
parturition  and  forced  defecation  or  urination  the  body  is  flexed  to 
bring  these  two  axes  in  the  same  vertical  plane,  so  that  the  abdominal 
pressure  may  act  to  the  greatest  advantage  in  the  pelvis. 

The  abdominal  cavity  is  not  identical  with  the  peritoneal  cavity,  for 
several  of  the  abdominal  viscera  are  extraperitoneal,  being  only  partly 
covered  by  peritoneum  (kidney,  duodenum,  etc.).  Such  viscera  may 
be  wounded  or  operated  upon  without  involving  the  peritoneum  which 
is  necessarily  involved  under  similar  circumstances  in  the  case  of  the 
intraperitoneal  viscera  (stomach,  small  intestine,  spleen,  liver,  etc.). 
Similarly  ;5mfo??/f  As  is  very  apt  to  be  caused  by  inflammation  or  perfora- 
tive ulceration  of  the  intraperitoneal  viscera,  but  not  necessarily  by  that 
of  the  extraperitoneal  viscera.  Thus  a  large  perinephritic  abscess, 
due  to  a  diseased  kidney,  very  rarely  involves  the  peritoneum,  while 
inflammation  of  the  appendix  or  perforation  of  the  small  intestine  sets 
up  a  local  or  general  peritonitis. 

The   Peritoneum. 

The  parietal  peritoneum  lines  the  deep  surface  of  the  abdominal 
wall  and  the  extraperitoneal  viscera.  It  is  thin  above,  thicker  below 
and  behind,  where  its  more  abundant  and  fatty  subperitoneal  tissue 
connects  it  loosely  with  the  abdominal  wall,  allowing  it  to  be  stripped 
up  in  operations  or  l)y  inflammations.  At  the  umbilicus  it  is  closely 
adherent  to  the  belly  wall  and  somewhat  less  adherent  along  the  back 
of  the  linea  alba. 

A  penetrating  wound  of  the  abdomen  is  one  which  penetrates  the 
peritoneum  as  well  as  the  other  layers  of  the  parietes.  Such  wounds 
are  much  more  serious  than  those  which  reach  to  but  not  through  this 
layer  for,  while  it  is  easy  to  set  up  inflammation  (peritonitis)  from  its 
inner  surface,  the  outer  surface  may  be  bathed  with  the  pus  of  an 
abscess  or  extensively  stripped  up  in  operations  without  ill  efft'cts. 
The  fact  of  penetration  in  an  abdominal  wound  is  often  difficult  to 
determine  clinically  and,  in  the  absence  of  definite  symptoms,  we  are 
justified  in  enlarging  bullet  and  stab  wounds,  rather  than  in  exploring 
with  the  probe. 

The  peritoneum  is  capable  of  great  stretching  if  it  is  effected  gradu- 
ally, as  seen  in  the  pregnant  uterus,  the  distended  bowel,  a  hernial 


THE  PERITONEAL  CAVITY.  285 

sac,  or  an  abdomen  distended  from  various  causes.  According  to 
Huschke  it  is  capable  of  hcdriuf/  <i  ircif/Jif  of  fiftv  j)()nnds,  an<l  its 
elasticity  is  well  shown  l)y  returning  to  its  |)revi(ins  condition  after 
removal  of  the  weight  as  well  as,  during  life,  after  the  removal  of 
ascites,  large  abdominal  tumors  and  the  ffctus  at  term.  It  is  possible 
for  the  parietal  peritoneum  to  be  ru]>tured  by  an  injury  which  does 
no  damage  to  any  of  the  viscera.  JiifhniuiKitioii  of  the  peritoneum 
and  its  results  interfere  vifh  its  distensibility  and  <lastieily,  and  may 
thus  disturb  the  functions  of  those  organs  which  are  covered  by  peri- 
toneum and  vary  in  volume  (uterus,  intestine,  bladder,  etc.). 

Like  other  serous  membranes  the  peritoneum  shows  a  strong  tend- 
ency to  adhciiion  between  two  opposed  surfaces  which  are  irritated  or 
inflamed.  By  the  stretching  of  these  adhesions  tiiere  may  be  formed  a 
variety  of  bands  beneath  which  loops  of  intestine  may  be  caught  and 
strangulated.  The  tendency  to  adhesion  is  made  nse  of  in  intcstiiud 
suture  in  which  the  peritoneal  surfaces  are  turned  in  so  as  to  oppose 
one  another.  Firm  adhesion  occurs  much  sooner  than  when  other 
soft  parts  are  united  by  suture.  Peritoneal  adhesions,  M'hether  pur- 
posely formed  or  the  result  of  inflammation,  often  show  a  tendencv  to 
become  smaller,  longer,  and  eventually  to  disappear,  when  the  cause 
of  irritation  is  removed. 

The  peritoneal  cavity  is  merely  a  capillary  interval  between  the 
contiguous  surfaces  of  the  viscera  which  are  covered  by  peritoneum, 
and  between  them  and  the  parietal  peritoneum.  It  is  a  closed  serous 
sac  except  in  the  female,  where  the  <)})enings  of  the  Fallopian  tubes 
connect  it  indirectly  with  the  body  surface.  This  sac  contains  just 
enough  peritoneal  fluid  to  lubricate  the  surfaces  and  diminish  friction. 
As  a  result  of  venous  congestion  a  large  amount  of  serous  fluid  mav 
be  effused  into  the  peritoneal  cavity.  This  is  known  as  ascites  (fVom 
0.(7X0^,  a  skin  bottle)  and  depends  upon  obstructed  venous  flow  in  the 
heart  or  lungs,  if  there  is  dropsy  elsewhere,  otherwise  the  obstruction 
is  probably  in  the  liver.  If  the  fluid  is  small  in  amount  it  collects  in 
the  flanks  on  lying  down,  or  the  hypogastric  or  inguinal  regions  on 
sitting  up;  if  in  greater  amount  it  distends  tiie  belly,  and  tlie  intes- 
tines float  on  top  in  whatever  position  the  body  is  in.  The  fluid  is  dull 
or  flat  on  percussion  and  sharply  marked  off  from  the  tympanitic  reso- 
nance of  the  intestines.  Breathing  may  be  easier  in  the  sitting  posture, for 
the  compressible  intestines  then  lie  beneath  the  crowded-np  diajihrairm. 

Tapping  of  ascites  may  be  practiced  in  the  semilunar  line  or  thelinea 
alba.  When  the  fluid  is  partly  withdrawn  the  end  of  the  trocar  is 
sometimes  closed  by  the  omentum  or  intestine,  which  can  be  dislodired 
by  introducing  a  ]irobe.  ^\.s  the  withdrawal  of  the  fluid,  b\-  reduein>r 
the  intra-abdominal  pressure,  causes  a  distension  of  the  deep  alulominal 
veins  and  thereby  robs  the  heart  of  its  wonted  supply,  faintness  is 
liable  to  occur,  but  may  be  prevented  by  the  pressure  of  an  abdominal 
binder. 

The  surface  (f  the  perito)\euiii  is  about  e(/ual  to  that  of  the  skin,  hence 
its  enormous  absorbing  function,  taking  up  in  one  hour  three  to  eight  per 


286  ,  THE  ABDOMEN. 

cent,  of  the  body  weight.  An  equal  transudation  or  exudation  may 
occur  from  very  toxic  or  irritant  substances.  Fluids  may  pass  through 
the  endothelial  layer  in  many  places ;  solids  are  carried  largely  by  leu- 
cocytes and  are  said  to  pass  only  through  the  intercellular  spaces  of  the 
peritoneum  covering  the  diaphragm  and  thence  into  the  mediastinal 
lymph  nodes.     The  presence  of  stomata  is  denied  by  Muscatello. 

There  is  normally  a  force  in  the  peritoneal  cavity  which  carries 
fluids  and  foreign  particles  toward  the  diaphragm,  regardless  of  the 
position  of  the  body  though  either  retarded  or  favored  by  it.  The 
peritoneum  in  a  healthy  state  is  capable  of  disposing  of  a  large  num- 
ber of  bacteria,  even  of  pyogenic  varieties,  without  ill  effects ;  but 
if  there  is  a  lesion  of  the  membrane,  or  anything  to  arrest  the  normal 
absorption,  so  that  the  bacteria  may  stagnate  and  multiply,  peritonitis 
results. 

If,  about  the  focus  of  a  commencing  peritonitis,  the  surrounding 
parts  become  glued  together  by  a  plastic  exudate  on  the  peritoneal  sur- 
face, the  peritonitis  may  be  limited  or  localized,  as  in  most  cases  of 
appendicitis.  If  the  adhesions  are  imperfect,  or  do  not  develop,  or 
the  focus  is  more  diffused,  the  peritonitis  is  progressive  until  it  becomes 
general.  The  latter  is  the  more  acute  form  and  in  it  the  muscular  coat 
of  the  bowel  and  its  nerve  plexuses  become  involved,  causing  intes- 
tinal paralysis.  The  result  of  this  is  constipation  or  complete  obstruc- 
tion of  the  bowels,  and  the  gas,  formed  by  the  decomposition  of  the 
intestinal  contents,  produces  distension  of  the  gut,  meteorism  or  tym- 
fjanites.  Hence  the  danger  of  giving  opium,  which  increases  these 
dangers.  Ti/mpxinites  raises  the  diaphragm  so  that  the  heart  and  lungs 
work  with  difficulty. 

In  peritonitis  the  least  pressure,  even  of  the  bed  clothes,  is  painful, 
hence  the  patient  lies  with  the  shoulders  raised  and  the  knees  drawn 
up,  to  relax  the  abdomen.  The  abdominal  walls  are  rigid  and  board- 
like and  the  diaphragm  is  kept  quiet  to  prevent  movement  of  the 
viscera,  respiration  being  pectoral.  In  colic,  on  the  other  hand,  pres- 
sure relieves  the  pain  and  the  lax  abdominal  walls  can  be  freely  moved 
over  the  bowels. 

The  visceral  peritoneum,  besides  covering  the  intraperitoneal  vis- 
cera, forms  folds  known  as  the  mesenteries  and  false  ligaments  to  attach 
these  viscera  to  the  parietes.  The  visceral  and  parietal  layers  of  the 
peritoneum  are  continuous  by  means  of  these  folds,  some  of  which 
deserve  especial  notice. 

The  great  omentum  is  the  elongated  mesentery  of  the  stomach 
which  is  connected  with  its  great  curvature,  or  attached  margin,  and 
descends  as  an  apron  in  front  of  the  bowels,  which  it  separates  from  the 
abdominal  walls.  In  well-nourished  persons  it  often  contains  consid- 
erable fat,  which  acts  like  a  cholera  band  in  maintaining  an  even  tem- 
perature of  the  bowels.  In  the  embryo  the  omental  fold  of  the  mesogas- 
triura  consists  of  four  peritoneal  layers  which  adhere  together  in  infancy 
and  thereafter  appear  to  consist  of  two  layers  containing  fat  and  blood 
vessels  between  them.     The  lesser  omental  sac  extends  down  between 


THE  GREAT  OMENTUM.  287 

the  two  anterior  and  the  two  posterior  omental  layers  before  they  ad- 
here together.  The  under  layers  as  they  pass  uj)  in  front  of  the  trans- 
verse colon  and  then  back  to  the  parietes,  l)cconic  adherent  to  the 
colon  and  to  the  npj)er  layer  of  its  mesocolon.  The  portion  of  omentum 
extending  from  the  great  curvature  of  the  stomach  to  the  anterior  sur- 
face of  the  transverse  colon,  to  which  it  is  attached,  forms  the  gastrocolic 
ligament  or  omentum.  It  and  the  transverse  mesocolon  prevent  <»ur 
reaciiing  the  posterior  surface  of  the  stomach  witiiout  passing  through 
one  or  the  other  of  them.  When  we  pull  down  the  omentum  the 
transverse  colon  and  stomach  are  pulled  down  and  the  former  may  be 
seen  through  it;  and  when  we  turn  up  the  omentum  we  see  the  trans- 
verse colon  attached  to  it.  Hence  the  omentum  may  be  used  to  find 
both  the  stomach  and  the  transverse  colon. 

The  omentum  extends  down  a  variable  distance  into  the  iliac  and 
hypogastric  regions,  hence  it  is  very  apt  to  he  found  in  hernkc  as  an  epip- 
locele.  This  is  said  to  be  more  common  on  the  left  side  because  the 
omentum  is  more  developed  on  this  side.  It  may  be  the  only  content 
of  a  hernia,  especially  in  cases  of  femoral  hernias  and  it  is  almost  con- 
stant in  umbilical  herniae,  except  in  the  congenital  variety  (see  umbil- 
ical hernia). 

The  omentum  generally  contracts  adJtesions  to  the  sac  of  a  hernia  in 
which  it  is  present,  provided  the  hernia  is  not  kept  reduced.  Such 
herniie  thus  become  irreducible,  and  the  omentum  may  form  a  kind  of 
second  sac  about  the  gut  and  often  grows  into  a  large  conglomerate 
fatty  )n((ss,  connected  with  the  rest  of  the  omentum  by  a  narrow  ped- 
icle passing  through  the  neck  of  the  sac.  When  the  omentum  in 
a  hernia  is  fit  to  be  returned  to  the  abdomen  the  intestine,  if  present, 
should  be  reduced  first. 

As  a  result  of  inflammation  the  omentum  may  contract  adhesions  to 
contiguous  parts  and  so  form  bands  beneath  which,  as  well  as  beneath 
adhesions  to  a  hernial  sac,  the  bowel  may  be  caught  and  strangulated. 
Strangulation  may  also  occur  through  holes  or  slits  in  the  omentum. 
Omental  adhesions  may,  under  certain  conditions,  exert  such  a  traction 
upon  the  stomacli  and  colon  as  to  produce  functional  disturbance.  A 
benign  cifect  of  omental  adhesions  is  seen  where  they  help  to  limit 
inflammatory  or  hemorrhagic  extravasations,  or  to  occlude  a  perfora- 
tion of  the  bowel  due  to  disease. 

The  omentum,  or  sometimes  a  separated  piece  of  it  {(nncntal  (/raff), 
is  occasionally  similarly  employed  by  the  surgeon  to  fortify  an  intes- 
tinal suture,  by  being  fastened  over  or  around  the  latter.  By  means 
of  adhesions  with  ovarian  tumors  the  latter  may  be  supplied  with 
blood  through  the  omentum,  in  case  its  blood  supply  is  cut  ofl^  by  the 
twisting  of  the  pedicle. 

From  its  exposed  position  iround.-<  of  the  omentum  are  common.  It 
may  plug  a  small  abdominal  wound  and  prevent  the  escape  of  other 
parts.  After  laparotou)y  it  is  well  to  replace  the  omentum  over  the 
bowels,  when  there  is  no  contrainilieation,  so  as  to  obviate  intestinal 
adhesion  in  the  line  of  the  cicatrix. 


288  THE  ABDOMEN. 

The  small  omentum,  extending  from  the  transverse  fissure  of  the 
liver  to  the  small  curvature  of  the  stomach,  helps  to  hound  the  lesser 
peritoneal  sac  in  front.  Its  rigid  border  extends  a  variable  distance 
on  to  the  first  portion  of  the  duodenum,  where  it  is  called  the  hepato-duo- 
denal  ligament.  The  latter  bounds  the  foramen  of  Winslow  in  front 
and  contains  between  its  two  thin  layers  the  portal  vein,  the  hepatic 
artery,  and  the  common  bile-duct,  the  vein  lying  behind  the  other  two, 
of  Avhich  the  bile-duct  is  to  the  right  of  the  artery.  Its  left  extremity 
encloses  the  a?sophagus. 

The  mesentery  is  attached  to  the  posterior  abdominal  wall  for  about 
six  inches.  This  attachment  commences  at  a  point  to  the  left  of  the 
second  lumbar  vertebra,  on  a  level  with  the  attachment  of  the  lower 
fold  of  the  transverse  mesocolon,  the  end  of  the  duodenum,  and  the 
lower  border  of  the  pancreas,  and  extends  thence  obliquely  downward 
and  to  the  right,  with  a  slight  convexity  to  the  left,  to  the  right  iliac 
fossa  or  to  the  right  sacro-iliac  articulation.  This  attachment  is  second- 
ary or  acquired,  its  real  attachment  is  mesial  and  about  the  origin  of 
the  superior  mesenteric  artery,  as  in  mammals  below  man.  Occasion- 
ally too  in  man  we  find  the  embryonic  type  of  the  single  median 
mesentery  for  the  entire  bowel. 

At  its  lower  end  the  right  layer  is  continuous  with  the  peritoneum 
covering  the  ascending  colon,  and  its  left  layer  with  the  mesentery  of 
the  appendix.  It  forms  a  posterior  longitudinal  partition  in  the  peri- 
toneal cavity,  and  its  oblique  course  directs  hemorrhagic  or  other  ex- 
travasations on  the  right  side  of  the  abdomen  first  into  the  right  iliac 
fossa  and  on  the  left  side  into  the  pelvis.  Hence  the  greater  frequency 
of  collection  of  blood  in  the  right  than  in  the  left  iliac  fossa. 

Between  its  two  layers  are  contained  blood  and  chyle  vessels,  nerves, 
fat  in  varying  quantity  and  lymphatic  nodes,  the  latter  especially  near 
its  attached  border.  In  addition  a  band  of  fibrous  tissue  and  plain 
muscular  fibers,  descending  from  the  left  cms  of  the  diaphragm  to  the 
end  of  the  duodenum,  passes  down  between  the  layers  of  the  mesentery 
and  is  of  sufficient  strength  to  support  the  weight  of  the  intestines  as 
well  as  to  resist  the  pressure  of  the  descent  of  the  diaphragm.  The 
name  suspensory  muscle  of  the  duodenum  and.  mesentery  is  suggested  by 
Lockwood  for  this  muscle.  Like  the  omentum  the  mesentery  may 
contain  tumors  of  various  kinds. 

The  leng'th  of  the  mesentery,  from  its  parietal  to  its  intestinal  attach- 
ment, varies  in  different  parts.  It  affords  great  mobility  to  the  small 
intestine,  allowing  it  to  be  displaced  by  tumors,  etc.  Its  average  length 
is  eight  to  nine  inches,  which  it  reaches  not  far  below  its  upper  end. 

That  part  which  is  connected  Avith  the  intestine  between  points  six 
and  eleven  feet  below  the  duodeno-jejunal  junction  attains  its  gradest 
length,  i.  e.,  ten  inches  (Treves).  This  part  of  the  intestine,  as  well 
as  the  lower  ileum,  is  thus  permitted  to  lie  in  the  pelvis.  According 
to  Treves,  Avhen  the  mesentery  is  normal  in  length,  no  part  of  the 
small  intestine  can  be  dragged  onto  the  thigh  through  the  femoral 
canal  (artificially  enlarged)  or  into  the  scrotum  through  the  inguinal 


THE  TRANSVERSE  MESOCOLOX.  289 

canal,  and  no  coil  of  intestine  can  be  drawn  out  of  the  abdomen  below 
a  horizontal  plane  passing  through  the  pubic  spine.  But  Lockwood 
states  that  it  is  quite  common  in  the  adult  to  find  that  the  small  intes- 
tines will  pass  H  inches  beyond  the  right  crm-al  arch,  up  to  the  left 
crural  arch,  and  one  inch  below  the  pubis.  Herniae  in  which  the  bowel 
occupies  positions  beyond  the  normal  are  common  and  require,  there- 
fore, a  /cnf/(h('iii)u/  of  the  mescufrrj/.  Whether  this  is  always  acquired, 
or  may  sometimes  be  congenital,  has  not  been  definitely  determined. 
According  to  Lockwood  the  mesentery  is  relatively  longer  in  infancy, 
but  rapidly  decreases  after  the  second  year.  The  length  of  the  mesen- 
tery is  an  important  factor  to  be  taken  into  account  in  the  production  of 
hernia.  The  position  of  the  mesentery  allows  intestinal  hernia  more 
freely  on  the  right  than  on  the  left  side. 

The  mesentery  may  contain  sUtn,  generally  due  to  injury,  or  round 
holes  of  con(fenital  orif/in,  through  which  the  intestine  may  be  stran- 
gulated. The  round  holes  are  in  an  oval  area  of  the  mesentery  of  the 
lower  ileum,  included  within  an  anastomotic  arch  betw^een  the  ileo-colic 
and  the  last  intestinal  branches  of  the  superior  mesenteric  artery,  which 
is  often  devoid  of  fat,  lymph  nodes  and  visible  blood  vessels,  and  is  so 
atrophied  that  a  knuckle  of  gut  might  easily  be  forced  through  it. 

The  mesentery  is  an  excellent  r/uide  to  lead  us  to  either  end  of  the 
small  intestine,  as  in  searching  for  intestinal  lesions.  Holding  up  a 
loop  of  the  intestine  vertically  w'e  trace  its  mesentery  back  to  its 
parietal  attachment  to  make  sure  that  it  is  not  twisted.  Assured  that 
the  mesentery  is  not  twisted,  we  follow  the  intestine  upward  from  the 
upper  end  of  the  loop  to  find  the  duodeno-jejunal  junction,  and  vice 
versa  to  reach  the  lower  end  of  the  ileum. 

The  transverse  mesocolon  is  three  to  four  inches  deep  and,  with  the 
transverse  colon,  reaches  from  the  posterior  to  the  anterior  abdominal 
wall  except  at  the  sides  of  the  abdomen.  It  forms  an  imperfect 
transverse  septum  between  the  lower  part  of  the  peritoneal  cavity, 
containing  the  small  intestine,  and  the  upper  part  containing  the  liver, 
stomach,  and  spleen.  To  a  certain  extent  and  for  a  time  it  may  limit 
a  peritonitis  on  one  side  from  extending  to  the  other.  This  protection 
is  also  increased  by  the  omentum  which  is  attached  to  the  colon  above 
and  descends  over  the  front  of  the  bowels.  The  transverse  mesocolon 
bounds  the  lesser  peritoneal  sac  below,  so  that  in  order  to  reach  the  pos- 
terior wall  of  the  stomach,  to  expose  an  ulcer  on  this  surface  as  well 
as  to  do  a  posterior  gastroenterostomy,  we  divide  the  mesocolon  verti- 
cally or  parallel  with  its  blood  vessels. 

The  lesser  peritoneal  sac,  betw'een  the  stomach  and  small  omentum 
in  front  and  the  pancreas,  etc.,  behind,  e.vtends  on  the  left  to  the  spleen 
and  the  left  kidney.  It  opci).'<  info  the  general  peritoneal  cavity  by  the 
foramen  of  Winslow.  The  latter  normally  admits  two  fingers  and 
through  it  an  internal  hernia  may  pass  and  become  strangulated 
(Rokitansky,  Blondin).  This  opening  may  become  narrowed  or 
closed  and,  in  the  latter  case,  a  kind  of  cyst  may  be  formed,  according 
to  Malgaigne  and  Begin. 
19 


290  THE  ABDOMEN. 

THE  ABDOMINAL  VISCERA.  . 

The  Stomach.     (Figs.  71,  72,  74,  75.) 

The  shape  of  the  stomach  is  like  that  of  a  pear,  bent  near  its  smaller 
end.  The  oesophagus  opens  into  it  at  the  right  side  of  its  larger  end, 
80  that  the  latter  projects,  as  the  fundus,  about  three  inches  to  the  left 
of  and  one  to  two  inches  above  the  oesophageal  orifice,  while  the  pyloru><, 
or  the  opening  into  the  duodenum,  is  at  the  smaller  end.  Therefore 
the  length  of  the  lower  or  left  border  is  the  greater,  hence  the  name 
greater  curvature.  The  lesser  curvature,  the  upper  or  right  border, 
meamres  from  three  to  five  inches  and  is  only  one  fourth  the  length  of 
the  greater  curvature.  The  great  curvature  is  convex  until  we  approach 
the  pyloric  end  where  there  is  a  slight  indentation,  between  which  and 
the  pylorus  there  is  a  slight  bulging,  the  antrum  pylori  (or  pyloric  por- 
tion). The  lesser  curvature  is  concave  except  over  the  antrum,  where 
it  is  slightly  convex. 

The  pylorus  can  be  seenas.  a  slight  constricti<.in  ixn(\  felt  as  a  thicken- 
ing. It  is  the  narrowest  part  of  the  alimentary  canal,  having  a  diameter 
of  one  half  inch,  hence  many  objects  may  be  swallowed  which  cannot 
pass  the  pylorus  and  must  be  removed  from  the  stomach  by  gastrotomy. 
This  is  especially  common  among  lunatics,  and  the  number  and  variety 
of  articles  swallowed  by  them  is  remarkable,  embracing  forks,  spoons, 
nails,  pebbles,  buttons,  coins,  keys,  etc.  Teeth  plates  are  not  uncom- 
monly swallowed  accidentally.  It  is  also  remarkable  in  some  instances 
how  large  an  object  can  be  swallowed  and  pass  the  pylorus,  i.  e.,  coins, 
buttons,  nails,  door  keys,  metal  pencil  holders  4|  inches  long,  etc. 
Needles  swallowed  find  their  way  through  the  stomach  and  bowels 
and  appear  at  various  points  in  the  body.  The  pylorus  is  liable  to 
obstruction  or  stenosis  from  several  causes.  The  atitrum  pylori  is  elon- 
gated so  that  it  resembles  the  intestine,  especially  in  the  female. 

The  cardiac  {or  oesophageal)  orifice  is  so  called  from  its  close  rela- 
tion to  the  heart.  The  two  surfaces  lying  between  the  two  borders 
are  nearly  symmetrical  and  look  ventrally  and  dorsally.  The  shape 
changes  with  age;  thus  some  say  that  it  is  nearly  cylindrical  at  hirth 
and  that  the  fundus,  although  it  grows  rapidly  in  the  first  year,  does 
not  attain  full  development  until  late  in  childhood.  Foetal  stomachs, 
however,  may  possess  a  well-developed  fundus.  In  the  female  the 
stomach  is  relatively  narrower.  No  definite  senile  changes  occur. 
The  shape  varies  with  the  degree  of  distension.  In  full  distension  the 
fundus  and  vertical  portion  are  most  affected.  In  the  empty  state  the 
surfaces  are  flattened  and  in  apposition.  During  digestion  a  constric- 
tion occurs  near  the  middle  of  the  stomach,  almost  completely  separat- 
ing the  cardiac  and  pyloric  halves.  In  some  cases  the  fundus  may 
appear  more  spindle-like  and  the  pyloric  half  cylindrical,  from  the 
uniformly  active  contraction  of  the  stomach  wall.  This  is  probably 
the  normal  shape  of  the  empty  stomach  during  life.  We  can  attach 
no  clinical  significance  to  the  general  shape  of  the  stomach  except  to 


PLATE    XXXV 


FIG.  71. 


Outline  of  ihe  abdominal   viscera,  showing  iheir  position  with 
relation  to  one  anothei-,  the  ribs  and  vertebrae.     (Merkel.) 


THE  POSITIOX  OF   THE  STOMACH.  291 

abnormalities,  such  as  those  due  to  diverticula,  bands  and  scars,  and 
hourgloHs-contraetion.  The  latter  may  be  either  pathological  or,  rarely, 
con^onital  in  origin.     Diverticula  are  very  rare. 

The  size  of"  the  stomach  varica  with  the  age,  sex,  and  degree  of  disten- 
sion as  well  as  in  certain  pathological  conditions.  The  avtrafjc  capacity 
at  birth  is  l-g  ounces;  at  three  months,  4i  ounces;  at  six  months,  6 
ounces ;  at  twelve  months,  9  ounces ;  at  eighteen  months,  1 2  ounces. 
In  the  adult  its  average  capacity  is  five  pints  (2}  liters),  though  it  may 
hold  perhaps  four  liters  witiiout  being  pathologically  enlarged.  But 
according  to  Ewald,  its  normal  limit  of  capacity  is  only  1,GOO  to  1,700 
c.c,  and  it  cannot  be  distended  by  more  than  lOO  c.c,  in  addition  to 
this.  In  gastrectasis,  or  dilatation  of  the  stomach,  the  capacity  may  be 
much  increased.     Dilatation  of  the  pyloric  portion  is  very  rare. 

Normally  when  full  its  oh/i<jiic  or  longed  diainctcr  measures  25-30  em., 
its  greatest  vertical  diameter  (at  the  cardia)  15  cm.,  its  antero-posterior 
diameter  10-12  cm.  at  the  fundus  and  3-4  cm.  at  the  antrum  pylori. 
The  distance  between  its  two  orifices  varies  from  three  to  six  inches. 
AVhen  empty  and  uniformly  contracted  it  is  scarcely  larger  in  diameter 
than  the  transverse  colon.  In  the  female  the  stomach  is  smaller  than 
in  the  male.     The  ireight  of  the  stomach  is  about  4  J  ounces. 

The  position  of  the  stomach  varies  more  than  that  of  any  other 
viscus  owing  to  its  mobility  and  varying  size.  It  lies  in  the  left  hypo- 
chondrium  and  the  epigastrium,  the  fundus  being  in  the  former  the 
rest  of  the  stomach  in  the  latter  region.  Only  in  occasional  instances 
does  it  extend  into  the  right  hypochondrium. 

The  cardiac  orifice  is  found  behind  the  seventh  left  costal  cartilage, 
one  inch  fntm  the  median  line,  to  the  left  side  of  the  tenth  or  eleventh 
thoracic  vertebra,  and  4i  inches  from  the  anterior  belly  wall.  Occasion- 
ally the  cardiac  orifice  is  found  in  the  median  line  or  even  somewhat 
to  the  right  of  it.  I  have  found  it  in  this  position  in  a  case  of 
gastrostomy  for  oesophageal  stenosis,  and  other  cases  are  reported. 
This  orifice  is  nearer  the  anterior  than  the  posterior  surface  of  the 
stomach  by  one  third  of  its  antero-posterior  diameter.  It  is  distant 
15|-  to  16  inches  from  the  incisor  teeth. 

The  fundus  extends  3-5  cm.  higher  than  the  cardiac  orifice  and  cor- 
responds to  the  superior  border  of  the  sixth  rib,  and  sometimes  to  the 
fifth  rib,  in  the  left  anterior  axillary  line,  to  the  sixth  left  ehondrosternal 
joint,  and  to  the  ninth  or  tenth  thoracic  vertebra.  Its  highest  part  lies 
directly  beneath  the  left  dome  of  the  diaphragm,  behind  and  above 
the  apex  beat  of  the  heart.  Its  close  relation  to  the  left  lung  and  the 
heart  explains  the  interference  with  their  function  when  the  stomach  is 
distended,  as  with  Hatulcnce,  which  causes  shortness  of  breath  and  palpi- 
tation of  the  heart.  Many  imagine  they  have  heart  disease  when  the 
real  trouble  is  indigestion.  Owing  to  the  position  of  the  fundus  the 
stomach  is  sometimes  wounded  in  wounds  of  the  lower  part  of  tiie 
pleural  cavity  ijivolving  the  diaphragm. 

The  great  curvature  in  its  upi)er  or  left  part  is  covered  by  the  dia- 
phragm, which  separates  it  from  the  lung,  the  sinus  of  the  pleura  and 


292  THE  ABDOMEN. 

the  thorax  as  we  follow  it  from  above  downward.  It  crosses  the  left 
costal  margin  about  the  junction  of  the  ninth  and  tenth  costal  cartilages. 
Inferiorly  it  extends  to  a  point  2  to  4  cm.  or  two  fingers'  breadth  above 
the  umbilicus,  and  further  to  the  right  it  ascends  along  the  median 
edge  of  the  gall-bladder.  A  normal  stomach  fully  distended  may 
even  reach  to  the  umbilicus,  and  in  cases  of  gastrectasis,  or  abnormal 
enlargement  of  the  stomach,  the  great  curvature  may  reach  any  level 
between  its  normal  position  and  the  symphysis.  This  condition  is  due 
to  an  obstruction  at  tlic  pylorus  from  cancerous  new  growth,  cicatricial 
stenosis  following  an  ulcer,  or  thickening  of  the  circular  muscle  of  the 
pylorus  in  some  forms  of  dyspepsia  with  hyperacidity.  The  enlarge- 
ment can  be  readily  made  out  by  inspection,  palpation,  and  percussion 
after  distending  the  stomach  with  air,  by  a  bicycle  pump  attached  to  a 
stomach  tube.  The  great  curvature  may  also  reach  a  Jou-  level  in 
gastroptosis,  or  a  downward  displacement  of  the  stomach.  This  condi- 
tion is  not  unlikely  at  times  more  of  a  vertical  enlargement  (without 
the  transverse)  than  a  displacement.  The  stomach  may  be  somewhat 
pulled  down  by  the  traction  of  the  omentum  adherent  to  the  sac  of  a 
hernia. 

On  the  other  hand  when  the  stomach  is  entirely  empty,  as  in  cases  of 
stricture  of  the  oesophagus,  the  stomach  is  high  up  under  the  left  lobe 
of  the  liver  and  the  costal  cartilages  and  far  back  in  the  abdomen,  so 
that  the  transverse  colon  projects  up  in  front  of  it  from  below  and 
(according  to  Sedillot)  the  anterior  border  of  the  spleen  overlaps  it 
from  the  side.  In  such  cases  it  may  be  hard  to  find,  but  this  can  be 
done  (1)  by  following  up  the  under  surface  of  the  liver  to  the  small 
omentum,  and  down  the  latter  to  the  stomach,  or  (2)  by  pulling 
down  the  omentum  and  following  it  up  to  the  stomach  over  the  colon, 
which  we  distinguish  by  the  longitudinal  bands  and  the  appendices 
epiploicae.  On  account  of  its  position  the  stomach  is  much  less  ex- 
posed to  injury  when  empty  and  the  injury  is  less  dangerous,  because 
of  the  little  extravasation  of  its  contents. 

The  lesser  curvature  lies  under  cover  of  the  left  lobe  of  the  liver 
except  in  cases  of  gastroptosis,  when  it  is  displaced  below  it.  It  de- 
scends nearly  vertically  in  front  of  the  left  crus  of  the  diaphragm  and 
the  left  side  of  the  last  two  thoracic  vertebrae,  from  the  oesophageal 
orifice  to  the  antrum,  where  it  turns  quite  sharply  and  passes  trans- 
versely to  the  right  at  the  level  of  the  first  lumbar  vertebra,  and  then 
slightly  upward  to  the  pylorus.  Three  fourths  or  four  fifths  of  the 
stomach  lie  to  the  left  of  the  median  line. 

The  pylorus  is  covered  by  the  quadrate  lobe  of  the  liver  3—4  cm.  to 
the  riffht  of  the  median  line  and  7  cm.  lower  than  the  cardiac  orifice 
or  the  sterno-xyphoid  articulation.  It  is  more  mobile  laterally  than 
vertically  and  its  radius  of  mobility  is  2-3  cm.  It  lies  near  the  median 
line,  in  line  with  the  right  border  of  the  sternum  when  the  stomach 
is  empty  ;  further  to  the  right  (3  inches  according  to  Braune)  when  it 
is  full.  In  general  it  corresponds  to  a  point  near  the  end  of  the  eighth 
right  costal  cartilage,  to  the  level  of  a  line  drawn  between  the  bony 


OPERATIOyS  ON  THE  STOMACH.  29S 

ends  of  the  seventh  ribs  in  front,  and  to  the  upper  border  of  the  first 
lumbar  vertebra  (or  the  twelfth  thoracic  spinej  behind.  The  difficulty 
of  palpating  tumors  of  the  pylorus  is  explained  by  its  being  covered 
by  the  liver,  except  occasionally  when  it  is  displaced  downwards  by 
the  new  growth  before  the  latter  gives  rise  to  adhesions.  The  antrum 
extends  further  to  the  right  than  the  pylorus  itself. 

From  the  above  facts  we  gather  that  the  axis  of  the  stomach  is  more 
vertical  than  formerly  supposed.  Down  to  the  antrum  it  is  nearly 
vertical  and  this  fact,  perhaps  combined  with  more  or  less  gastroptosis 
or  gastrectasis,  accounts  for  the  sword-swallowing  feats.  The  axis  of 
the  stomach  is  sometimes  more  vertical  in  infants,  retaining  some  of 
the  vertical  position  of  the  embryo,  and  in  some  cases  it  remains  so  in 
the  adult. 

The  anterior  surface  of  the  stomach  is  in  contact  with  the  diaphragm 
and  the  anterior  thoracic  wall,  which  covers  the  fundus  ;  to  the  right 
of  this,  with  the  liver  above  and  the  abdominal  wall  below.  The  liver 
covers  the  pylorus  and  the  parts  just  below  the  lesser  curvature,  and 
leaves  a  more  or  less  triangular  area  where  the  stomach  is  in  contact 
iritli  the  abdominal  wall.  This  triangle  is  bounded  on  the  left  by  the 
eighth  and  ninth  costal  cartilages  ;  on  the  right  by  the  free  margin  of 
the  liver,  passing  from  the  ninth  right  to  the  eighth  left  costal  carti- 
lage ;  and  below  by  the  transverse  colon,  or  a  line  joining  the  tips  of 
the  tenth  costal  cartilages. 

Throuf/h  thin  triaiif/lc  we  reach  the  stomach  in  the  various  operations 
on  that  viscus.  The  incision  may  extend  above  the  right  border  of  the 
triangle  for  the  free  margin  of  the  liver  can  be  retracted  upward.  The 
line  of  incision  may  be  vertical,  in  the  median  or  semilunar  lines  or 
through  the  rectus  muscle,  or  oblique,  parallel  with  and  an  inch  from 
the  left  costal  margin.  In  the  latter  case  the  part  of  the  incision 
external  to  the  rectus  divides  the  three  flat  abdominal  muscles. 
Behind  the  rectus  we  meet  with  the  superior  epigastric  artery,  which 
we  avoid  or  ligate.  Of  these  operations  the  most  important  are  gas- 
trotomy,  gastrostomy,  gastroenterostomy,  pyloroplasty  and  pylorectomy. 

In  gastrotomy  the  stomach  is  opened  anteriorly  to  remove  foreign 
bodies,  to  treat  a  stricture  of  the  oesophagus  by  retrograde  dilatation, 
or  for  exploration. 

In  gastrostomy  a  ga^^tric  fistula  is  established  in  order  to  feed  the 
patient  when  there  is  a  cancerous  stricture  of  the  oesophagus.  The 
many  recent  modifications  of  the  technique  of  gastrostomy  have  aimed 
at  prerentinc/  leakarje  of  the  stomach  contents.  This  is  more  or  less 
perfectly  secured  in  v.  Hacker's  method,  by  using  the  se])arated  fibers 
of  the  rectus  as  a  sphincter,  in  Witzel's  method  by  making  a  long 
oblique  fistula  surrounded  by  the  muscle  of  the  stomach  wall,  in 
Kader's  and  Senn's  method  by  inverting  a  small  cone  of  the  stomach 
wall  as  a  valve,  etc. 

In  gastroenterostomy  an  anastomosis  is  made  between  a  low  point  in 
the  stomach  and  the  upper  part  of  i\\Q  jejunum,  when  the  outlet  of  the 
stomach  is  obstructed.     Though  formerly  done  through  the  anterior 


294  THE  ABDOMEN. 

stomach  loall,  it  is  now  most  often  done  through  the  posterior  wall  to 
avoid  the  reflux  of  bile  and  the  vomiting  which  may  follow  the  anterior 
method.  But  if  the  anastomosis  occupies  the  most  dependent  position 
it  probably  makes  little  difference  whether  it  is  anterior  or  posterior. 
The  posterior  irall  is  readied  through  an  opening  in  the  transverse  meso- 
colon, and  a  Murphy  button  is  commonly  used  to  make  the  anasto- 
mosis. When  done  for  non -malignant  conditions  the  good  results  are 
permanent. 

Pyloroplasty  is  employed  in  cases  of  pyloric  stenosis,  and  the  pyloric 
opening  is  enlarged  by  suturing  a  longitudinal  incision  in  a  transverse 
direction. 

Pylorectomy  has  been  employed,  since  its  introduction  by  Billroth, 
in  cases  where  a  cancer  of  the  pyloric  end  of  the  stomach  is  removable. 
The  large  opening  left  after  resection  of  the  tumor  is  closed  until  it 
corresponds  in  size  to  the  duodenum,  or  altogether  closed  and  a  gastro- 
enterostomy added. 

How  is  the  Stomach  Held  in  Position? — The  stomach  is  attached 
oiUij  at  the  cardia,  the  pylorus  is  fastened  to  the  posterior  abdominal 
wall  through  its  connection  with  the  duodenum.  The  stomach  is  also 
supported  by  the  gastrophrenic  ligament  from  the  diaphragm,  to  the  left 
of  the  oesophagus,  and  by  the  lesser  omentum  from  the  transverse 
fissure  of  the  liver.  The  thickened  right  border  of  this  omentum  ex- 
tends on  to  the  first  part  of  the  duodenum  as  the  hepato-duodenal 
ligament  and  helps  to  support  the  pylorus.  The  cardia  and  pylorus 
are  the  most  fixed  points,  and  the  lesser  curvature,  attached  at  either 
end  to  these  fixed  points,  cannot  change  its  relative  position  to  any 
extent,  hence  it  is  the  more  fixed  border  of  the  stomach.  It  moves 
slightly  with  respiration.  In  the  gradual  distension  of  the  stomach  by 
gas,  not  by  water,  the  anterior  surface  becomes  more  superior  by  a 
rotation  on  the  lesser  curvature  as  an  axis,  which  brings  the  greater 
curvature  upward  and  forward.  When  full  the  stomach  rests  upon 
the  transverse  colon  and  mesocolon,  so  that  the  latter  and  the  hepato- 
colic  and  phrenocolic  ligaments,  which  help  to  support  the  colon,  assist 
in  supporting  the  stomach.  The  stomach  is  not  supported  by  intra- 
abdominal pressure. 

The  stomach  is  also  connected  with  otiier  structures.  At  the  great 
curvature  the  peritoneum  covering  the  front  and  back  surfaces  of  the 
stomach  meet  and  pass  down  as  the  great  omentum.  This  is  the  orig- 
inal mesentery  of  the  stomach.  Its  left  extremity,  the  gastrosplenic 
omentum,  connects  the  stomach  with  the  spleen  and  inferiorly  the  por- 
tion known  as  the  gastrocolic  ligament  connects  the  stomach  with  the 
transverse  colon. 

Other  relations  of  the  stomach.  The  posterior  surface  of  the  stomach 
rests  in  great  part  on  the  transverse  mesocolon,  above  this  on  the  pan- 
creas, with  the  splenic  vessels  along  its  upper  border,  more  to  the  left 
on  the  splenic  flexure  of  the  colon,  the  upper  half  of  the  left  kidney, 
the  entire  left  suprarenal  capsule,  and  the  anterior  surface  of  the  spleen. 
In  addition  the  crura  of  the  diaphragm,  the  aorta,  the  vena  cava  inferior, 


VESSELS  OF  THE  STOMACH.  295 

the  fourth  portion  of  the  duodcnuni  and  the  solar  plexus  also  lie  behind 
the  stomach.  Between  the  pancreas,  kidney,  and  suprarenal  capsule 
beiiind,  and  the  stomach  in  front  lies  the  h'sacr  pcritoiKdl  sar.  Per- 
Joratiny  ulcers  of  the  posterior  wall  of  the  stomach  may  open  into  this 
sac  or,  after  adhesion,  into  one  of  the  viscera  named  as  lying  behind 
it,  causing  perhaps  an  abscess  of  the  organ  so  invaded.  Cases 
are  recorded  where  such  ulcers  have  given  rise  to  ulceration  of  the 
.splenic  artery,  causing  a  fatal  hemorrhage  into  the  stomach.  On 
cross-section  of  the  abdomen  the  stomach  is  seen  to  lie  between  the 
liver  and  the  spleen,  so  that  it  may  be  displaced  by  enlargements  of 
either  of  these  organs. 

Layers  of  the  Stomach  Wall. — J*eritoneuiii  covers  the  entire  stomach 
except  for  a  narrow  strip  along  the  lesser  and  greater  curvatures,  where 
the  anterior  and  posterior  layers  are  continuous  with  the  small  and 
great  omenta  respectively,  and  where  the  vascular  trunks  run.  This 
serous  layer  is  closely  bound  by  a  scanty  subserous  tissue  to  the  thick 
muscular  layer.  Only  in  a  distended  stomach  does  the  peritoneum 
retract  somewhat  on  incision.  The  muscular  tissue  is  quite  thick,  so 
that  in  suturing  there  is  more  for  the  sutures  to  hold  to  and  less 
danger  of  the  needle  penetrating  all  the  coats  than  in  intestinal  suture. 
Owing  to  the  difference  in  direction  of  the  fibers  of  the  three  layers 
and  of  the  line  of  their  retraction  on  division,  gastric  vmunds  are  raggefl 
and  not  likely  to  gape.  If  small  they  may  be  quite  eifectually  plugged 
by  the  protrusion  of  the  mucous  membrane,  Avhich  is  permitted  by  the 
looseness  of  the  submucous  tissue  The  latter  also  allows  the  mucous 
menihranem  an  actively  contracted  stomach  to  form  prominent  longitu- 
dinal folds,  more  marked  toward  the  pyloric  end  and  along  the  great 
curvature,  which  greatly  reduce  its  lumen.  In  a  moderately  contracted 
stomach  slight  folds  are  seen  bounding  irregular  shallow  depressions. 
The  latter  may  partly  or  wholly  disapj)ear  when  the  stomach  is  relaxed. 
There  is  a  zigzag  line  encircling  the  cardiac  orifice  on  its  inner  surface 
opposite  the  tenth  thoracic  vertebra,  where  the  thick  columnar  epithe- 
lium of  the  gastric  mucosa  joins  the  thinner  squamous  epithelium  of 
the  oesophageal  mucosa. 

Vessels. — The  arteries,  derived  from  the  gastric,  hepatic  and  splenic 
branches  of  the  cd'liac  axis,  run  along  both  curvatures  of  the  stomach 
and  from  both  ends,  anastomosing  where  they  meet.  Branches  pass 
from  these  trunk  vessels,  at  right  angles  to  the  trunks  and  to  the  axis 
of  the  stomach,  over  both  surfaces  where  they  anastomose  on  meeting. 
The  veins  take  the  same  course.  Hence  an  incision  parallel  with  and 
near  the  curvatures  divides  many  of  these  branches  where  they  are 
largest,  and  considerable  hemorriiage  results.  Near  the  curvatures 
incisions  at  right  angles  to  them  (/.  c,  parallel  with  the  vessels)  cause 
less  bleeding,  while  midway  between  the  curvatures  incisions  parallel 
with  them  occasion  but  little  hemorrhage.  If  the  larger  trunk  vessels 
are  concerned  in  a  gastric  ulcer  and  become  adherent  to  the  stomach 
wall  and  finally  eroded,  serious  hemorrhage  into  the  stomach  may 
'•esult.     The   veins  mipfi/  info  the  jxn-fal  vein  either  directly  or  through 


296  THE  ABDOMEN. 

the  splenic  and  superior  mesenteric.  Hence  the  varicose  gastric  veins 
and  the  coiu/csfioH  of  the  stomach  with  hemorrhage  into  it,  in  cirrhosis  of 
the  liver,  or  cardiac  disease  accompanied  by  portal  obstruction. 

The  lymphatics  of  the  stomach  form  a  superficial  or  subserous,  and 
a  deep  or  submucous  set.  These  empty  into  vessels,  with  an  occasional 
small  nolle,  along  both  curvatures  of  the  stomach.  Those  on  the  lesser 
curvature  run  toward  the  cardia  and  empty  into  lymph  nodes  there, 
those  on  the  great  curvature  accompanying  the  gastroepiploic  arteries 
run  into  the  lymph  nodes  above  the  pancreas  on  the  right  side,  and 
into  those  at  the  hilum  of  the  spleen  on  the  left  side.  This  distribution 
is  to  be  borne  in  mind  in  searching  for  the  metastatic  growths  of  gastric 
tumors. 

Nerves. — The  atderior  and  postenor  gastric  plexxscs,  formed  by  the 
left  and  right  pneumogastric  nerves  respectively,  together  with  branches 
from  the  sympathetic,  lie  near  the  lesser  curvature  at  its  cardiac  end. 
The  synipatheiic  fibers  from  the  coeliac  plexus  accompany  the  gastric 
artery  to  and  along  the  lesser  curvature  as  the  coronary  plexus.  They 
anastomose  with  the  pneumogastric  fibers  and  supply  largely  the 
pyloric  half  of  the  posterior  wall.  It  will  be  noticed  that  the  plexuses 
are  along  and  near  the  lesser  curvature  especially  at  its  cardiac  end, 
explaining  the  reflex  palpitation  of  the  heart,  faintness,  or  asthma 
which  may  occur  after  going  to  bed  with  the  stomach  full  of  an  undi- 
gested meal,  which  then  presses  against  the  lesser  curvature  and  irritates 
the  nerves.  After  vomiting  the  attack  subsides.  Irritation  of  the 
gastric  pneumogastric  filaments  may  be  misinterpreted  by  the  brain  as 
an  irritation  of  the  pulmonary  fibers  and  give  rise  to  a  "stomach 
cough."  Irritation  of  the  pneumogastric  filaments  in  the  neck,  brain 
or  stomach  (from  disease,  concussion,  or  in  a  sea  voyage)  may  cause 
vomiting. 

Congenital  malformations  of  the  stomach  are  rare.  It  may  be 
displaced  in  cases  of  transposition  of  the  viscera  and  of  congenital  de- 
ficiencies of  the  diaphragm  or  anterior  body  wall.  Complete  congeni- 
tal atresia  of  the  pylorus  is  very  rare,  stenosis  of  the  pylorus  is  more 
common.  In  certain  cases  hourglass-contraction  is  probably  of  con- 
genital origin,  in  most  cases  it  is  due  to  cicatricial  contraction  following 
ulcer  or  corrosive  poison,  and  it  is  very  much  more  common  in  females 
than  in  males. 

The  pathological  conditions  affecting  the  anatomy  of  the  stomach  are 
chiefly  ulcer  and  cancer.  Ulcer  occurs  along  the  lesser  ciirratiire  in  33.6 
per  cent.;  on  the  posterior  wall  in  29.6  per  cent.;  at  the  pylorus  in  1 2  per 
cent.'  Occurring  so  often  on  the  lesser  curvature,  pain  does  not  come 
on  so  quickly  after  a  meal  as  in  case  of  gastric  catarrh,  where  the  great 
curvature  is  chiefly  involved,  for  pain  occurs  only  when  the  food  is  in 
contact  with  the  ulcer,  hence  vomiting  brings  relief.  Gastric  ulcer  is 
usually  single  and  varies  in  size  from  a  5  cent  piece  to  that  of  a  quarter 
of  a  dollar.  It  is  liable  to  perforate  through  the  stomach  and  give 
rise  to  a  circumscribed  abscess,  if  adhesions  take  place,  otherwise  to  a 
'  Welch's  analysis  of  793  cases. 


THE  DUODENUM.  297 

general  peritonitis.  The  cicatricial  ronfrai-floit  following  an  ulcer  at  the 
pylorus  narrows  the  orifice  and  causes  pyloric  obnfrnctioii.  This  causes 
at  first  a  hypertrophy  of  the  stomach,  to  overcome  the  obstruction, 
but  later  on  this  gives  place  to  dilatation  and  its  sequela?.  An  liour- 
(jlass-coiitraction  may  result  from  the  cicatricial  contraction  if  the  ulcer 
occurs  in  the  body  of  the  stomach.  Ad/ir.s-ioit.s  to  contiguous  viscera 
may  cause  violent  gastralgias  owing  to  the  traction  on  the  stomach. 
Seventy-five  per  cent,  of  cancers  of  the  stomach  are  of  the  scirrhous 
form,  and  this  variety  affects  the  ])ylorus  in  sixty  per  cent,  of  the 
cases,  where  sooner  or  later  it  usually  obstructs  the  orifice  with  the 
resulting  sequela?.  Lijinphatir  infection  is  said  to  be  less  frequent  and 
less  rapid  than  in  cancer  elsewhere. 

Sfricfiirc  of  the  pylorus  may  also  be  due  to  the  pressure  of  tumors  ex- 
ternal to  it,  or  to  hypertrophy  of  the  circular  sphincter  fibers,  resulting 
from  dyspepsia  with  hyperacidity  which  causes  a  violent  and  long-con- 
tinued contraction  of  the  pylorus.  In  (liapJiraf/inatic  /ternia  I  have  seen 
the  stomach  in  the  left  pleural  cavity,  and  many  such  cases  are  recorded. 
A  part  of  the  stomach  may  occasionally  be  found  in  an  umhilical  Iiemia. 
The  stomach  may  be  raptured  by  a  contusion.  There  is  more  danger 
of  this  when  the  stomach  is  full  and  hence  in  closer  contact  with  the 
abdominal  wall. 

Vomiting  is  effected  by  the  abdominal  muscles  compressing  the 
stomach  against  the  liver  and  diaphragm.  The  latter  is  depressed  to 
its  lowest  level  by  a  full  inspiration  and  fixed  by  the  closure  of  the 
glottis,  so  that  a  patient  with  an  opening  in  the  trachea  cannot  vomit. 
As  vomiting  is  naturally  easier  with  a  full  stomach  plenty  of  warm 
water  should  be  given  with  an  emetic.  Eructation  is  accomplished  by 
the  muscular  action  of  the  stomach  alone. 

The  Small  Intestine. 

The  small  intestine,  extending  between  the  pyloric  and  ileocrecal 
valves,  averages  in  length  in  the  adult,  independently  of  height,  weight 
or  age,  22}  feet  in  the  male  and  23^  feet  in  the  female.  In  the  infant 
at  birth  it  averages  9}-  feet.  The  diameter  decreases  from  its  upper  to  its 
lower  end,  from  IJ^  or  2  inches  in  the  duodenum  to  1^  inches  in  the 
loAver  ileum. 

The  duodenum  (Figs.  71,  72,  74,  17)  antl  77)  or  first  portion,  is 
the  only  part  having  a  fixed  position  or  extent  (ten  to  twelve  inches). 
It  lies  in  great  part  retroperitoneally.  In  shapje  it  forms  a  kind  of 
spiral  within  which  is  the  head  of  the  pancreas.  Its  natural  division 
into  three  or  four  parts  is  useful  in  studying  its  relations. 

The  first  part  (or  superior  longitudinal  portion)  is  about  two  inches 
long  and  is  the  most  ntovahle  part  on  account  of  its  peritoneal  relations. 
Its  entire  anterior  surface,  and  the  first  inch  or  so  of  its  posterior  sur- 
face next  to  the  ])ylorus,  are  covered  by  peritoneum  derived  from  the 
right  end  of  the  lesser  omentum.  This  is  known  as  the  liganieulum 
hepato-duodcmde  and  is  continuous  with  the  peritoneum  of  the  stomach. 
Thus  this  portion  of  the  duodenum  is  allowed  to  follow  the  moveracnts 


298 


THE  ABDOMEN. 


of  the  stomach,  and  so  avoid  undue  traction.  The  direction  of  this 
segment  is  nearly  horizontal  and  varies  with  the  fullness  of  the  stomach. 
When  the  stomach  is  distended  and  the  pylorus  is  pushed  over  to 
the  right  it  passes  nearly  directly  backwards.  When  the  stomach  is 
empty  its  course  is  nearly  transverse  from  left  to  right,  with  only  a 
slight  inclination  backward,  and  between  these  extremes  its  direction 
varies  according  to  the  condition  of  the  stomach.  Its  distal  end  is 
fixed  at  the  level  of  the  first  lumbar  vertebra,  under  the  quadrate  lobe 
of  the  liver,  or  the  neck  of  the  gall-bladder,  so  that  it  is  found  stained 
by  bile  at  a  post-mortem.  It  forms  the  lower  boundary  of  the  foramen 
of  Winslow.  The  common  bile-duct,  the  vena  portse  and  the  hepatic 
artery  pass  behind  it ;  the  head  of  the  pancreas  lies  heloir  it. 

Fig.  72. 


RIGHT  SUPRARENAL 
CAPSULE 


LEFT  SUPRARENAL 

I      CAPSULE 


J  I    LINE   OF   REFLECTION 
OF  MESOCOLON 


LINE    OF    REFLECTION 
OF    MESENTERY 


DUODENO-JEJUNAL 
JUNCTION 


Abdiiuiiual  viscera  from  in  front,  after  His'  models. 

Behind  the  neck  of  the  gall  bladder  it  bends  downward  into  the 
second  part,  which  de.'icends  for  nearly  three  inches  to  the  right  of  the 
first,  second,  and  third  lumbar  vertebrae  and  in  front  of  the  renal  ves- 
sels, the  vena  cava  and  the  inner  edge  of  the  right  kidney.  These  rela- 
tions are  to  be  borne  in  mind  in  operations  on  the  right  kidney.  About 
its  middle  it  is  crossed  in  front  by  the  attachment  of  the  two  layers  of  the 
transverse  mesocolon,  between  which  it  is  entirely  bare  of  peritoneum 
and  nearly  in  contact  with  the  right  end  of  the  transverse  colon.  The 
parts  of  the  second  portion  above  and  below  the  mesocolon  are  covered 
with  peritoneum  in  front  only.  This  peritoneum  is  continuous,  above 
the  mesocolon,  with  the  upper  layer  of  the  latter,  laterally  with  that 
covering  the  front  of  the  right  kidney  and  mesially  with  the  gastro- 
colic ligament.  Below  the  mesocolon  the  peritoneum  is  continuous 
with  its  inferior  layer. 

The  snpracolio  portion  is  in  contact  vith  the  under  surface  of  the 
right  lobe  of  the  liver,  on  which   it  forms  an  impression   (impressio 


THE  DUODENUM.  299 

duodenalis)  to  tlie  right  of  the  neck  of  the  gall-bladder.  To  the  left 
of  it  lies  the  head  of  tlie  pancreas,  and  between  the  two  the  pancreatico- 
duodenal artery  in  front,  and  the  common  l)ile-duct  behind.  It  is 
bound  to  parts  behind  it  by  areolar  tissue,  which  allows  of  its  easy 
separation  and  some  change  in  position  of  the  duodenum  in  the  trans- 
verse direction.  Downward  shifting  is  entirely  prevented  by  the  fixa- 
tion of  the  first  part  by  the  hepato-duodenal  ligament,  and  in  this  way 
any  traction  on  the  pancreatic  and  common  bile-ducts,  and  the  result- 
ing functional  disturbance,  is  prevented. 

The  supracolic  portion  and  the  first  part  of  the  duodenum  are 
exposed  between  the  liver  and  the  transverse  colon  by  pulling  the  latter 
up  and  the  former  down,  and  following  the  pylorus  to  the  right.  Some- 
times, on  account  of  a  high  position  of  the  transverse  colon  and  meso- 
colon, but  little  of  the  duodenum  is  to  be  found  above  them.  By  incis- 
ing the  peritoneum  on  the  right  side  of  the  upper  end  of  the  second 
j)art  we  may  elevate  the  gut  and  reach  the  lower  end  of  the  common 
bile-duct.  The  latter,  usually  in  common  with  the  pancreatic  duct, 
enters  the  duodenum  at  the  end  of  a  papilla  on  the  inner  and  dorsal 
aspect  of  the  second  portion,  about  three  to  four  inches  from  the 
pylorus. 

On  the  interior  of  the  duodenum  at  the  junction  of  the  first  and 
second  portions,  is  a  crescentic  fold  of  mucous  membrane,  on  the  inner 
and  posterior  aspect.  According  to  Brewer,  this  fold  is  permanent,  is 
made  prominent  l)v  pulling  the  bend  upward,  averages  1.9  inches  from 
the  pyloric  valve  and  1.4  inches  from  the  papilla,  and  may  be  useful 
in  finding  the  latter. 

Ulcer  of  the  duodenum,  as  compared  with  gastric  ulcer,  is  uncommon, 
but  the  writer  has  known  of  a  number  of  cases  where  perforation  has 
occurred  and  resulted  fatally.  Unlike  gastric  ulcer  it  occurs  more  often 
in  males  (three  to  one).  Its  association  with  burns  and  scalds  was 
formerly  much  emphasized,  but  is  now  believed  to  be  very  uncommon. 
Its  diagnosis  is  nearly  impossible.  The  perforations  are  apt  to  be 
about  two  inches  from  the  pylorus  and  severe  hemorrhage  often  com- 
plicates the  case  and  renders  surgical  treatment  a  forlorn  iiope,  although 
the  only  one.  Cicatrization  may  result  in  stricture.  Brunner\s  glands, 
which  are  said  to  be  the  seat  of  perforating  ulcers  in  cases  of  burns, 
are  mostly  in  the  upper  part  of  the  duodenum,  and  perforation  of  such 
ulcers  is  apt  to  bo  intraperitoneal. 

The  tliird  or  transverse  portion  of  the  duodenum,  nearly  five  inches 
long,  extends  from  the  right  side  of  the  third  lumbar  vertebra  across 
the  latter  to  the  left  of  the  third  or  second  lumbar  vertebra,  cro.%s-ing 
in  front  of  the  crura  of  the  diaphragm  and  the  great  vessels.  It 
crosses  the  vena  cava  where  the  left  renal  vein  enters  it.  It  is  the 
most  fixed  part  of  the  duodenum,  and  is  only  covered  in  front  by  peri- 
toneum continuous  with  the  lower  layer  of  the  mesocolon.  Where 
the  superior  mesenteric  vessels,  which  emerge  between  it  and  the  pan- 
creas, and  the  root  of  the  mesentery  cross  the  front  of  the  duodenum, 
the  latter  is  free  of  peritoneum. 


300  THE  ABDOMEN. 

The  fourth,  or  ascending  part,  about  an  inch  long,  ascends  in  front 
of  the  left  eras  of  the  diaphragm  to  the  second  or  first  lumbar  verte- 
bra, so  that  the  end  and  the  beginning  of  the  duodenum  are  nearly  at 
the  same  level.  It  ends  by  turning  forward  into  the  jejunum  at  the 
duodeno-jejunal  angle.  This  part  is  firmly  held  in  place  by  a  band  of 
fibrous  tissue,  containing  some  muscle  fibers,  that  descends  from  the 
left  crus  of  the  diaphragm  and  is  continued  into  the  mesentery  between 
its  folds  (the  suspcnsori/  musde  of  the  duodenum  and  mesentery,  Lock- 
wood).  (See  Mesentery.)  The  duodeno-jejunal  bend  remains  unal- 
tered in  position  no  matter  how  much  the  stomach  and  intestines  are 
displaced.  Peritoneum  covers  the  fourth  portion  in  front  and  partly  at 
the  sides. 

In  about  50  per  cent,  of  the  cases  examined,  a  fold  of  peritoneum  is 
to  be  found  passing  from  the  anterior  surface  of  this  portion  of  the 
duodenum  to  the  parietal  peritoneum  on  its  left  side.  This  fold  is  the 
anterior  boundary  of  a  triancjular  pouch  which  lies  to  the  left  of  the 
gut  and  is  known  as  the  fossa  duodeno-jejunalis,  or  Treitz'  fossa.  Its 
apex  is  below  the  bend  between  the  third  and  fourth  portions,  the 
opening  lies  superiorly  and  admits  the  tip  of  the  finger  and  sometimes 
of  the  thumb.  The  fold  is  the  remains  of  the  fcetal  ^^  duodenal  fold ^ 
The  duodeno-jejunal  junction  actually  occupies  the  fossa.  The  fossa  is 
exposed  by  retracting  the  transverse  colon  upward  and  the  upper  end 
of  the  jejunum  to  the  right.  It  is  important  as  being  the  starting 
point  of  a  retroperitoneal  hernia.  This  is  small  at  first  but,  gradually 
dilating  the  fossa,  the  latter  may  eventually  contain  nearly  the  entire 
small  intestine,  as  in  the  case  reported  by  Sir  Astley  Cooper,  and  in 
several  others  observed  since. 

All  parts  of  the  duodenum  have  been  ruptured  by  violence,  though 
this  is  not  common.  The  duodenum  may  be  vounded  from  behind 
without  opening  the  peritoneum,  owing  to  its  large  non-peritoneal  sur- 
face. Only  the  first  portion  has  ever  been  found  in  a  hernia.  It 
will  be  noticed  that  the  shape  of  the  duodenum  is  not  unlike  that  of  a 
trap  used  in  plumbing,  and  it  is  not  unlikely  that  it  acts  as  such,  pre- 
venting tlie  regurgitation  of  intestinal  gas  into  the  stomach. 

The  jejunum  (jejunus — empty,  i.  e.,  the  condition  in  which  it  is 
usually  found  after  death)  and  the  ileum  (£?/crv — to  twist,  i.  e.,  the  curved 
or  twisted  intestine),  lie  for  the  most  part  inside  of  the  more  fixed 
large  intestine.  Their  attachment  to  the  posterior  abdominal  wall  hi/ 
the  mesentery  allows  of  such  free  motion  of  the  coils  on  one  another 
that  they  are  well  adapted  to  withstand  the  effects  of  pressure  and  con- 
tusion, an  important  fact,  for  of  all  viscera  they  are  most  exposed  to 
injury. 

In  consequence  of  the  freedom  of  motion  of  the  coils  of  small  intes- 
tine a  definite  and  constant  position  of  the  different  parts  is  not  possi- 
ble. Yet  in  general,  they  are  disposed  in  an  irregularly  curved  manner 
from  the  left  to  right,  and  the  jejunum  is  largely  above  the  ileum  and 
occupies  the  umbilical  and  left  lumbar  and  iliac  regions,  while  the 
ileum  is  found  in  the  pelvis,  the  hypogastrium  and  the  right  side.     For 


THE  JEJUNUM  AXD   ILEUM.  301 

directions  for  following  the  jejunum  and  ileum  to  either  end  see  Mes- 
entery, page  289.  Often  the  coils  of  the  jejunum  are  arranged  trans- 
versely, those  of  the  ileum  vertically. 

Some  coils  of  the  jejunum,  corresponding  to  the  longest  part  of  the 
mesentery,  are  found  in  t/ic  pelvis.  The  terminal  coils  of  the  ileum 
just  proximal  to  the  ileocnecal  valve  are  also,  as  a  rule,  found  in  the 
pelvis.  The  coils  of  the  ileum  and  jejunum  occupying  the  pelvis  are 
of  interest  as  they  are  apt  to  become  involved  and  adherent  in  pelvic 
peritonitis,  and  would  probably  be  found  among  the  contents  of  obtu- 
rator, sciatic  and  pudendal  hernite.  The  f(fffi I  jjclcin  contains  no  small 
intestine,  and  the  amount  ])resent  in  the  adult  pelvis  dej)ends  upon  the 
distension  of  the  bladder,  rectum  and  sigmoid  flexure,  and  the  size  of 
the  female  pelvic  organs. 

The  ileum,  or  lowest  part,  is  that  most  frequently  found  in  inguinal 
or  femoral  Jicriti<r,  though  the  jejunum,  from  its  position  in  the  left 
iliac  fossa,  would  also  be  likely  to  be  present  in  left  inguinal  or 
femoral  iiernia.  Hence,  theoretically,  the  symptoms  of  obstruction 
would  be  likely  to  be  more  acute  in  a  strangulated  hernia  on  the  left 
side  than  in  one  on  the  right  side,  because  the  jejunum  is  more 
likely  to  be  present  in  the  former.  In  this  connection  we  may  say  that 
inte.sfiiial  obsinidion,  or  other  lesions  of  the  intestine,  are  more  serious 
the  nearer  they  are  to  the  stomach,  and  hence  are  more  serious  in  the 
jejunum  than  in  the  ileum.  In  obstruction  of  the  jejunum  nutrition  is 
interfered  with,  vomiting  commences  early  and  is  very  frequent,  the 
ai)domen  is  but  little  distended,  the  expression  becomes  quickly  pinched 
and  anxious,  and  the  jirogress  of  the  case  is  rapid  and  acute;  while  in 
similar  lesions  of  the  ileum  the  reverse  is  true.  The  acuteness  of  the 
symptoms  and  the  fatality  of  strangulated  umbilical  hernia  may  depend 
partly  upon  its  liability  to  contain  coils  of  the  upper  jejunum. 

The  ileum,  from  its  position,  is  more  apt  to  be  strangulated  by  in- 
ternal bands,  holes  in  the  mesentery,  etc.  The  coils  of  intestine  must 
accommodate  themselves  each  moment  to  changes  in  form  and  position 
of  the  peritoneal  cavity,  depending  upon  the  movements  of  the  dia- 
phragm and  abdominal  muscles,  the  filling  or  emptying  of  the 
viscera,  the  presence  of  effusions,  tumors,  etc.  Hence  the  rigid  fixity 
of  the  abdominal  muscles  and  the  absence  of  diaphragmatic  breath- 
ing in  ]ierit()nitis,  to  diminish  the  movements  of  the  infiamed  j^eri- 
toneal  surfaces.  A  similar  object  is  sought  in  the  ()j>ium  treatment 
of  peritonitis  by  decreasing  the  ])eristaltic  movements  of  the  coils 
against  one  another.  Abdominal  tumors  cause  a  displacement  or 
change  of  position  of  the  intestines,  which  varies  with  the  size  and 
position  of  the  tumor  and  is  useful  in  the  diagnosis  of  the  latter.  In 
like  manner  the  small  intestine  floats  on  the  fluid  in  cases  of  ascites  so 
as  to  be  mostly  in  front  or  above,  according  as  the  ]xitient  is  reclining 
or  erect.  The  upper  part  of  the  jejunum  and  the  lower  part  of  the 
ileum  are  the  most  fixed  portions,  as  their  mesentery  is  shorter  than 
elsewhere.  I5ut  the  jejunum,  two  feet  or  less  from  its  upper  end,  is 
freely  enough   movable  to  allow  it  to  be  drawn    up    without   tension 


302  THE  ABDOMEN. 

over  the  transverse  colon  and  fastened  to  the  stomach  in  anterior  gastro- 
enterostomy. 

Though  the  upper  two  fifths  of  the  small  intestine  below  the  duo- 
denum is  called  the  jejunum  and  the  lower  three  fifths  the  ileum,  there 
is  no  definite  point  where  one  may  be  said  to  end  and  the  other  to 
begin.  It  is  often  difficult  to  tell  to  which  part  a  given  coil  belongs 
when  it  is  exposed  by  operation  or  accident,  especially  if  the  size  or 
appearance  is  altered  by  disease.  But  between  the  upper  end  of  the 
jejunum  and  the  lower  end  of  the  ileum  there  is  considerable  differ- 
ence. The  diameter  of  the  former  is  1\  inches,  of  the  latter  \\ 
inches.  The  walls  of  the  former  are  more  vascular  and  thicker,  owing 
largely  to  the  valvulse  conniventes  which  are  large  and  numerous, 
while  they  are  nearly  wanting  in  the  lower  part  of  the  jejunum  and 
scanty  in  the  upper  part  of  the  ileum.  If  the  intestine  is  opened 
and  presents  a  large  number  of  well-developed  valvulte  conniventes 
we  may  infer  that  the  opening  is  in  the  upper  jejunum,  and  if  few  or 
no  valvulse  conniventes  that  it  is  in  the  lower  ileum.  If  we  look 
through  the  empty  gut  toward  a  light  the  lines  of  the  valvulae  conni- 
ventes can  be  well  seen.  The  contents  also  vary  in  the  two  parts  of  the 
bowel  considered,  corresponding  to  the  stage  of  digestion. 

In  the  persistent  vomiting  of  intestinal  obstruction  or  peritonitis, 
after  the  stomach  is  emptied  the  bowel  contents  are  regurgitated  by 
reverse  peristalsis  and  are  vomited.  The  character  of  the  vomit 
changes  from  the  sour  stomach  contents  to  the  bitter  bile-laden  con- 
tents of  the  upper  bowel,  and  finally  the  matter  may  become  faecal. 
Faical  or  stercoraceous  vomiting  usually  means  vomiting  of  intestinal 
contents,  though  the  latter  do  not  really  become  faecal  in  odor  or  char- 
acter above  the  lower  ileum. 

The  Layers  of  the  Intestinal  Wall. — The  peritoneal  coat  is  so 
nearly  complete  that  a  wound  from  without  or  a  perforation  from 
within  can  scarcely  occur  without  involving  it.  Between  the  two  lay- 
ers of  the  mesentery  where  they  pass  onto  the  bowel,  there  is  a  strip 
of  the  latter  averaging  ^^^  of  an  inch  in  width  uncovered  by  peri- 
toneum. This  area  is  the  usual  cause  of  the  occasional  leakage  after 
enterorrhaphy,  for  the  essential  feature  of  the  operation  is  that  the 
serous  coat  of  both  ends  of  the  divided  gut  should  be  brought  together 
at  all  points.  In  enterorrhaphy  or  in  the  use  of  the  Murphy  button,  or 
other  aids  to  intestinal  anastomosis,  the  two  layers  of  the  mesentery, 
where  they  pass  onto  the  bowel,  should  be  carefully  brought  closely 
together  by  suture  so  as  to  complete  the  circle  of  the  serous  coat. 
Loss  of  substance  of  a  limited  area  of  the  peritoneal  coat  may  occur 
without  serious  impairment  of  the  strength  or  function  of  the  part  of 
the  bowel  involved,  though  strong  adhesions  are  likely  to  occur  here. 

The  inner  or  circular  muscular  coat  is  three  times  as  thick  as  the 
outer  layer  of  longitudinal  fibers,  hence  a  longitudinal  wound  gapes 
more  than  a  transverse  one.  Owing  to  the  greater  thickness  of  the 
longitudinal  fibers  along  the  free  border  of  the  gut,  transverse  wounds 
across  this  part  of  the  gut  gape  more  than  elsewhere.     Wounds  of  the 


THE  JXTESTIXAL    WALL.  303 

jejunum  gape  more  than  those  of  the  ileum,  owing  to  the  greater  mus- 
cular development  of  the  former.  MinnJc  iroiinch  of  the  intestine  are 
closed  by  the  contraction  of  the  muscular  coat  so  as  to  prevent  extrava- 
sation. The  bowels  have  been  punctured  without  ill  effects  in  many 
places  to  allow  the  escape  of  gas  when  excessive  tympanites  exists  and 
in  abdominal  operations  to  facilitate  the  return  of  the  intestine  witiiin 
the  al)domen.  At  present,  however,  fewer  and  larger  openings  are 
usually  made  and  afterwards  sutured.  Wounds  somewhat  larger  than 
punctures  are  plugged  by  the  protrusion  of  the  loose  mucous  mem- 
brane which  mayor  may  not  prevent  extravasation.  Treves'  men- 
tions a  stab  wound  with  a  small  puncture  of  the  ileum  which  remained 
closed  by  such  a  protrusion  of  mucous  membrane,  aided  liy  recent 
lymj)h,  for  four  days  when  fatal  symptoms  suddenly  occurred,  and  it 
was  found  post  mortem  that  an  intestinal  worm  (Ascaris  lumbricoides) 
had  escajx'd  through  the  wound  and  led  the  way  for  extravasation. 

In  larger  wounds  the  size  of  the  opening  is  much  reduced  bv  mus- 
cular contraction.  Thus  Gross  found  in  longitudinal  wounds  a  reduc- 
tion in  length  of  one  half.  The  mucous  membrane  is  also  greatly 
everted  by  reason  of  the  muscular  contraction,  and  this  is  to  be  remem- 
bered in  intestinal  suture,  for  it  must  be  inverted  in  order  to  bring  the 
edges  of  the  serous  membrane  together  and  thereby  secure  firm  heal- 
ing of  the  wound,  for  mucous  membrane  does  not  unite  with  mucous 
membrane  on  its  epithelial  surface. 

In  order  to  secure  the  healing  of  intestinal  wounds  the  serous  as 
well  as  the  mucous  layers  are  somewhat  inverted  1)V  Lemberf  sitfiire.'<. 
The  latter  suture  catches  up  the  serous  and  muscular  layers  external 
to  the  line  of  the  wound,  so  that  the  suture  punctures  do  not  reach  the 
latter  but  leave  a  narrow  free  strip  on  either  side  of  it.  Thus 
when  the  sutures  are  tightened  the  strips  of  the  peritoneal  coat  l)e- 
tween  the  two  lines  of  suture  punctures  on  each  side  are  brought  in 
contact,  M'hile  the  edges  are  inverted  and  are  also  in  contact  with  one 
another. 

The  worm-like  peristaltic  movements  of  the  intestine  are  the  result 
of  the  consecutive  contraction  of  successive  i)ortions  of  the  muscuhir 
coat.  Abnormally  this  action  may  be  reversed,  as  in  intestinal  ob- 
struction, and  force  the  contents  toward  the  stomach  instead  of  toward 
the  colon  and  thus  produce  fjecal  vomiting. 

The  caliber  of  the  intestine  varies  with  the  contraction  of  its  mus- 
cular wall.  When  empty  the  bowel  becomes  contracted.  It  may  be 
distended  by  accumulated  ffecal  matter  or  by  gas.  In  septic  peritoni- 
tis and  in  some  other  septic  conditions  the  muscular  wall  in  time  be- 
comes paralyzed  by  sejitie  poisoning.  Peristalsis  therefore  ceases  aiul 
obstruction  follows,  while  the  stagnant  ftecal  matter  develops  iras 
which  distends  the  bowel.  From  the  muscularis  mucosic  of  sheep 
comes  the  "cafr/uf"  of  commerce,  so  much  used  in  surgery. 

The  mucous  membrane  is  /ooseli/  coiinecftd  with  the  layers  beneath  so 
as  to  permit  it   to  move  freely  over  them.      This  allows  it  to  become 

'Surj,Mc;il  A|i|iliod  Anatoiuv. 


304  THE  ABDOMEN. 

everted,  so  as  to  plug  a  small  wound,  and  to  become  prolapsed  in  some 
cases  of  artificial  anus,  thus  preventing  spontaneous  closure, 

Feyei-'s  patcliei^,  occurring  principally  in  the  ileum  and  especially  in 
its  lower  two  thirds,  are  placed  lengthwise  of  the  intestine  on  the  side 
opposite  the  mesenteric  attachment,  and  hence  are  best  exposed  by 
opening  the  gut  along  the  attachment  of  the  mesentery.  They  are  the 
seat  of  typhoid  as  well  as  tubercular  ulcers,  the  former  of  which 
usually  extends  longitudinally  in  the  axis  of  the  patch,  the  latter 
transverselv  in  the  direction  of  the  encircling  blood  vessels.  In  one 
case  of  perforating  typhoid  ulcer,  on  which  the  writer  operated,  the 
long  axis  of  the  ulcer  was  transverse. 

The  vessels  of  the  small  intestines  eider  or  emerge  from  the  bowel 
along  the  narrow  strip,  uncovered  by  peritoneum,  at  the  mesenteric 
attachment.  The  arteries  run  transversely  from  either  side,  thus  en- 
circling the  gut.  This  arrangement  of  the  arteries  sometimes  enables 
us  to  distinguish  the  intestines  from  other  structures  in  case  of  doubt. 

The  large  anastomosing  branches,  which  lie  between  the  two  layers 
of  the  mesentery,  are  liable  to  be  injured  in  stab  or  gunshot  wounds 
and  to  give  rise  to  serious  hemorrhage. 

The  veins  accompany  the  arteries  singly,  and  flow  through  the 
superior  mesenteric  into  the  portal  vein.  Hence  they  are  affected  by 
portal  congestion  in  some  conditions  of  the  liver,  and  septic  infection 
may  be  carried  by  them  to  the  latter  from  the  intestine,  sometimes 
producing  abscess  of  the  liver. 

The  lymphatics  form  two  sets  as  in  the  stomach,  a  deep  set  in  the 
mucous  membrane,  and  a  superficial  set  in  the  muscular  layer.  In  the 
mesentery  they  are  known  as  chyle  vessels  on  account  of  the  milky 
fluid  they  contain.  They  enter  numerous  (100-200)  lymph  nodes 
between  the  folds  of  the  mesentery,  at  and  near  its  parietal  attach- 
ment, which  are  subject  to  enlargement  in  lesions  of  the  intestine  like 
tuberculosis,  enteric  fever,  dysentery,  cancer,  etc.  In  case  of  enlarge- 
ment of  these  nodes  the  lesion  should  be  sought  in  the  intestine. 

The  nerves  come  from  the  cceliac  and  superior  mesenteric  plexuses  of 
the  sympathetic,  with  some  fibers  from  the  right  pneumogastric.  For 
the  connection  between  the  nerves  of  the  intestine  and  those  of  the 
aixlomiual  wall  see  the  latter  (p.  251). 

Meckel's  diverticulum,  a  persistent  proximal  portion  of  the  vit- 
elliue  duct,  is  a  blind  glovefinger-like  pouch  having  the  same  layers  as 
the  ileum  and  a  lumen  continuous  with  it.  It  arises  from  the  free 
margin  of  the  ileum  from  one  to  three  feet  from  its  lower  end.  It 
averages  two  or  three  inches  in  length  but  may  be  much  larger,  and 
ends  in  a  free  cylindrical,  conical  or  globular  extremity  or  in  a  fibrous 
band  which  may  connect  it,  as  in  fatal  life,  with  the  umbilicus,  or 
with  other  parts.  It  can  cause  ob.strucfioii,  when  its  end  is  adherent, 
by  forming  a  bridge  beneath  which  a  loop  of  bowel  may  be  strangulated 
or  by  pulling  on  the  ileum  at  its  attachment  so  as  to  kink  the  latter. 
It  occurs  once  in  about  fifty  cases,  has  been  found  in  external  heruise 
and  may  even  giv^e  rise  to  a  condition  resembling  appendicitis. 


OPERATIONS  ON  THE  SMALL  INTESTINE.  305 

In  operations  upon  the  intestines,  or  in  penetrating  abdominal  wounds 
which  may  involve  them,  it  is  to  be  remembered  that  they  are  sepa- 
rated in  great  part  from  the  anterior  abdominal  wall  by  the  great 
omentum.  As  the  omentum  is  the  only  thing  that  intervenes  between 
the  intestines  and  the  abdominal  wall  the  intestinrs  are  much  exposed  to 
eontiiHion>i  by  blows,  the  effects  of  which  are  intensified  if  received  una- 
wares, when  the  belly  wall  is  relaxed,  or  if  the  body  cannot  Ix^nd  or 
yield  to  the  blow.  In  this  way  the  intestine  may  Ije  torn,  severed  or 
so  bruised  as  to  slough  subsequently  and  thus  lead  to  a  fatal  result. 
This  possibility  should  be  borne  in  mind  in  cases  of  severe  abdominal 
contusions  and  the  prognosis  be  reserved. 

In  bullet  or  stab  wounds,  penetrating  and  traversing  the  abdomen, 
the  intestines  almost  always  receive  multiple  injuries,  the  number  of 
which  varies  but  is  generally  greater  in  those  wounds  whose  course 
is  transverse  or  oblique,  because  more  coils  of  intestine  are  thus  met 
with.  Occasionally  a  bullet  or  knife  may  pass  among  the  intestines 
without  wounding  them.  Several  such  cases  are  reported  where  the 
fact  has  been  demonstrated  by  operation,  but  it  occurs  in  less  than  two 
or  three  per  cent,  of  cases.  A  bullet  whose  course  passes  through 
near  the  edge  of  a  piece  of  intestine  makes  a  larger  opening  than  one 
passing  through  the  center,  and  the  wound  of  entrance  and  exit  may 
be  continuous  if  they  lie  along  the  edge  of  the  gut. 

Along  the  ileum  as  well  as  the  colon  diverticula  may  occur,  nearly  as 
large  as  the  bowel  itself.  These  are  due  to  a  hernial  protrusion  of  the 
mucous  membrane  through  the  muscular  coat. 

The  end  of  the  ileum  may  slip  through  the  ileocsecal  valve  and 
become  prolapsed  into  the  colon,  possibly  even  to  the  anus.  This  is 
one  variety  of  intussusception  and  occurs  mostly  among  children.  It 
may  sometimes  be  reduced  by  forced  inflation  of  the  bowel  soon  after 
it  has  happened,  and  before  the  adjacent  serous  surfaces  have  finally 
adhered  together. 

Operations. — Laparotomy  or  cceliotomy  applies  simply  to  the  pro- 
cedure of  opening  the  abdominal  cavity  for  any  purpose  and  is  referred 
to  under  the  abdominal  wall,  p.  253.  The  bowel  may  be  opened  [en- 
terotomy)  to  remove  an  impacted  foreign  body,  in  which  case  it  is 
sutured  immediately;  or  to  make  an  artificial  anus  above  an  obstruc- 
tion, after  the  intestine  is  sutured  into  the  wound.  The  permanent 
opening  of  the  bowel  below  an  obstruction  and  its  suture  into  the 
wound  for  the  purpose  of  feeding  the  patient  {enterostomy),  is  usually 
done  in  the  upper  jejunum  (jejunostomy),  so  that  the  food  may  pass 
through  the  greatest  possible  length  of  intestine,  but  the  operation  is 
not  very  popular.  In  enterectomy  a  portion  of  tiie  bowel  is  cut  out 
or  resected  for  gangrene,  tumors,  stricture,  multiple  injuries  from  bullet 
or  stab  wounds  and  many  other  causes.  In  a  successful  case  of  clos- 
ure of  sixteen  bullet  wounds  of  the  small  intestine,  reported  by  the 
writer,  three  or  four  inches  of  the  gut  were  resected,  as  there  were 
four  holes  within  two  inches,  the  closure  of  which  would  have  caused 
a  stricture  or  kinking  of  the  bowel.  The  successful  resection  of  two 
20 


306  THE  ABDOMEN. 

meters  of  the  intestine  has  been  reported,  and  many  cases  where  more 
than  one  meter  has  been  resected. 

After  resection  intestinal  suture  is  performed,  preferably  by  the  end 
to  end  suture  or,  if  it  is  not  possible  to  bring  the  ends  together  with- 
out tension,  lateral  anastomosis  may  be  made  after  inverting  and  clos- 
ing the  divided  ends.  As  a  palliative  operation  lateral  anastomosis 
is  often  made  between  the  coils  above  and  below  a  lesion  Avithout 
resection  of  the  diseased  parts.  The  end  to  end  suture  is  preferable  if 
feasible,  for  peristalsis  will  follow  its  natural  course  and  there  is  little 
or  no  danger  of  stricture  from  contraction  of  the  opening.  Various 
mechanical  aids  to  facilitate  both  forms  of  intestinal  union  and  to  save 
time  have  been  devised,  among  the  most  perfect  of  which  is  the 
Murphy  button.  The  importance  of  securing  perfect  apposition  of  the 
opposing  peritoneal  surfaces  throughout,  in  intestinal  wounds  or  oper- 
ations, has  been  referred  to  above. 

The  Large  Intestine. 
Ileocaecal  Region. 

The  caecum  (Fig.  73),  or  blind  head  of  the  colon,  is  the  large  cul  de 
sac  of  the  colon  that  lies  below  the  entrance  of  the  ileum.  In  man  and 
the  carnivora  it  is  rudimentary,  while  in  the  herbivora  and  graminiv- 
ora  it  is  of  great  size,  so  that  in  man  it  has  been  called  an  anatomical 
protest  against  vegetarianism.  Its  uidth,  three  inches,  is  greater  than 
its  length,  2|  inches,  and  it  is  relatively  and  absolutely  larger  in  the 
adult. 

As  to  shape,  four  types  may  be  distinguished.  (1)  The  feetcd  or 
infantile  type  is  conical  with  the  root  of  the  appendix  at  the  small  end 
of  the  cone,  where  the  longitudinal  bands  are  about  equidistant.  This 
persists  in  about  two  per  cent,  of  cases  among  adults.  In  type  2  the 
appendix  still  comes  off  from  the  lower  end  at  the  meeting  point  of 
the  three  bands,  but  on  either  side  of  it  the  csecum  is  expanded  into 
two  equal  sacculi.  It  occurs  in  the  adult  in  three  per  cent,  of  cases. 
Type  3  is  the  common  or  normal  form,  occurring  in  man  in  ninety  per 
cent,  of  cases.  In  it  the  right  sacculus  and  the  anterior  wall  have  out- 
grown the  left  side  so  that  they  form  the  lower  end  of  the  ciecum  while 
the  root  of  the  appendix,  to  which  converge  the  longitudinal  bands, 
has  been  displaced  upward,  inward  and  backward,  to  about  f  of  an 
inch  below  the  entrance  of  the  ileum.  The  longitudinal  hands  are 
thus  seen  to  be  a  uniform  and  useful  guide  to  the  base  of  the  appendix. 
The  anterior  band  is  our  best  guide  to  the  root  of  the  appendix,  for  it 
is  the  most  accessible.  Type  4,  comprising  four  or  five  per  cent,  of 
cases,  is  an  exaggeration  of  3,  in  which  the  root  of  the  appendix  is  dis- 
placed to  the  inferior  ileocaecal  angle  by  the  atrophy  of  the  left  sacculus. 

The  csecum  is  the  most  superficial  portion  of  the  large  intestine. 
When  full  it  occupies  most  of  the  iliac  fossa  and  is  in  contact  with  the 
anterior  abdominal  wall,  but  when  empty,  as  after  fasting  or  when 
there  is  obstruction  in  the  small  intestine,  it  is  smaller  and  covered  by 


THE  C^CUM.  307 

coils  of  the  small  intestine.  Its  normal  position  is  in  the  right  iliac 
fossa,  on  the  psoas  muscle,  above  the  outer  half  of  Poupart's  ligament, 
with  its  apex  projecting  over  the  inner  edge  of  that  muscle  and  lying 
a  little  to  the  inside  of  the  middle  of  Poupart's  ligament.  It  may 
sometimes  lie  further  mesially,  extending  down  into  the  pelvis  or 
toward  or  even  across  the  median  line.  In  other  cases  it  may  lie 
more  to  the  right,  entirely  on  the  iliacus  muscle  or  with  only  its  apex 
on  the  psoas.  It  is  not  infrequently  displaced  doicmrard  so  as  to  Vje 
found  in  a  right  inc/ninal  or  femoral  Jiernia.  Such  hernite  are  provided 
with  a  complete  peritoneal  sac  except  in  rare  cases. 

The  fcdal  civcuin  is  situated  at  first  within  the  umbilical  region, 
thence  it  ascends  into  the  left  hypochondrium  from  which  it  passes  across 
into  the  right  hypochondrium  and  then  descends  into  the  right  iliac 
fossa.  An  interesting  and  important  variation  in  the  position  is  that 
in  which  it  remains  undescended  from  its  fretal  position  above  and  to 
the  left  of  the  umbilicus,  the  ascending  and  transverse  colon  being 
absent.  More  often  it  is  partly  descended  and  just  below  the  liver  or 
at  any  point  between  the  liver  and  its  normal  position.  Accordingly 
it  may  even  be  found  in  a  congenital  umbilical  hernia.  It  is  not  un- 
common to  find  the  csecum  unusually  high  on  the  right  side,  having 
been  arrested  in  its  descent  into  the  right  iliac  fossa.  The  writer  has 
met  with  such  cases  in  operating  for  appendicitis  where  the  csecum 
was  above  the  crest  of  the  ileum.  The  importance  of  these  irregular 
positions  of  the  coecum  lies  in  the  fact  that  the  appendix  is  correspond- 
ingly shifted. 

The  direction  of  the  csecum  is  not  quite  vertical  but  it  inclines 
slightly  inward  below.  If  we  take  as  its  upper  limit  the  lower  edge  of 
the  ileocolic  junction  the  cai^cum  is  completely  covered  by  peritoneum. 
The  latter,  therefore,  is  first  reflected  onto  the  iliac  fossa  from  the  as- 
cending colon,  so  that  the  subperitoneal  areolar  tissue  of  the  iliac  fossa 
is  never  in  direct  contact  with  the  posterior  surface  of  the  csecum, 
which  is  free  in  the  peritoneal  cavity.  The  level  of  this  reflection  of 
peritoneum  and  of  the  upper  end  of  the  caecum  varies,  but  is  usually 
about  midway  between  the  level  of  the  anterior  superior  spine  and  of 
the  highest  point  of  the  iliac  crest.  Quain,  Berry  and  others  state 
that  in  five  per  cent,  of  cases  the  peritoneum  is  reflected  just  below  the 
upper  end,  leaving  the  posterior  wall  of  that  part  connected  with  the 
subperitoneal  areolar  tissue,  but  they  make  the  caecum  reach  a  higher 
level,  /.  e.,  that  of  the  ilcoca^cal  valve.  The  mobility  of  the  caecum 
de])ends  largely  upon  the  distance  between  its  tiji  ami  the  reflection  of 
peritoneum  posteriorly  from  the  colon,  and  upon  the  presence  of  an 
ascending  mesocolon.  A  mobile  csecum  may  even  find  its  way  into 
a  left  inguinal  or  femoral  hernia.  In  some  caecal  hernire  the  yicvi- 
toneum  of  the  iliac  fossa  and  its  reflection  onto  the  lower  end  of  the 
colon  appears  to  have  slid  down  so  as  to  form  part  of  the  posterior 
wall  of  the  sac. 

Foreign  bodies  that  have  been  swallowed  and  have  passed  the  pylorus 
are  apt  to  lodge  in  the  cfecura,  where  they  may  ulcerate  through  the 


308  THE  ABDOMEN. 

caecal  wall  and  cause  perityphlitis.  The  largest  accumulation  of  faeces 
in  cases  of  /cecal  impaction  is  often  found  in  the  csecum.  Hence  ster- 
coral ulcers,  due  to  the  pressure  irritation  of  retained  or  impacted  fsecal 
masses,  are  more  common  in  the  csecura  than  in  any  other  part  of  the 
intestine.  The  caecum,  according  to  Cobbold,  is  the  seat  of  the  jnn 
u-orm  (oxyuris  vermicularis),  but  others  claim  that  this  is  lower  down 
in  the  colon.     Intestinal  concretions  are  not  uncommonly  met  with  here. 

In  cases  of  intestinal  obstruction  the  condition  of  the  caecum  may 
assist  us  in  diagnosis.  If  the  obstruction  be  in  the  colon  the  caecum 
wnll  be  found  greatly  distended,  while  it  is  normal  or  collapsed  in 
cases  of  obstruction  of  the  small  intestine.  The  caecum  is  capable  of 
enormous  distension,  if  gradually  effected,  and  has  been  observed  larger 
than  the  full  stomach.  Flexing  the  thigh  upon  the  abdomen  will 
empty  a  slightly  distended  caecum,  if  normal  in  position.  The  struc- 
ture of  the  caecum  is  like  that  of  the  colon,  the  peculiarities  of  which 
are  described  later. 

The  ileocaecal  or  ileocolic  valve  guards  the  entrance  of  the  ileum 
into  the  large  intestine  at  the  junction  of  the  caecum  and  colon.  It  is 
normally  found  on  the  internal  and  posterior  aspect  of  the  large  intestine, 
but  rarely,  by  a  rotation  of  the  latter,  the  ileum  may  pass  behind  it 
and  open  on  its  outer  side,  or  it  may  open  more  in  front  when,  occa- 
sionally, the  posterior  part  of  the  caecum  is  more  developed  than  the 
anterior.  The  valve  consists  of  tivo  flaps  formed  by  the  invagination 
of  the  ileum  into  the  colon.  It  is  corajwsed  of  the  mucosa,  submucosa 
and  circular  fibers,  while  the  peritoneum  and  longitudinal  fibers  pass 
directly  over  the  angle  between  the  ileum  and  the  large  intestine  and 
form  no  part  of  the  valve.  Hence,  if  the  two  outer  layers  are  divided 
and  traction  is  made  on  the  ileum,  the  valve  is  unfolded  and  pulled  up 
into  the  ileum,  which  then  presents  a  funnel-shaped  opening  into  the 
large  bowel.  The  two  flaps  project  nearly  transversely  into  the  lumen 
of  the  large  intestine  and  this  projection  is  continued  from  either  end  of 
the  slit-like  opening  for  a  short  distance  around  the  circumference  of  the 
colon  as  the  fraena,  or  retinacula,  of  the  valve,  similar  to  a  plica  of  the 
colon,  so  that  the  valve  may  be  said  to  open  on  the  summit  of  a  plica. 

When  the  caecum  and  colon  are  distended  the  flaps  of  the  valve  are 
pressed  together,  preventing  regurgitation  into  the  ileum.  In  an 
ordinary  high  enema  the  valve  renders  impossible  the  passage  of  the 
fluid  into  the  ileum,  but  if  a  high  pressure  is  steadily  continued  the 
fluid  may  pass  the  valve,  though  probably  not  before  peritoneal  lacera- 
tions and  other  damage  to  the  large  intestine  have  occurred.  Hence 
practically,  for  diagnostic  and  therapeutic  purposes,  the  valve  is  not 
j^ervieable  to  fluids  from  below,  and  the  attempt  to  force  fluids  past  the 
ileocaecal  valve  from  below  is  unsafe  and  unjustifiable.  Some  say  that 
high  enemata  may  pass  the  valve  in  a  considerable  projxjrtion  of  cases, 
but  in  these  cases  the  valve  is  regarded  as  imperfect  and  incompetent  from 
the  first.  With  air  or  gases  it  is  otherwise  ;  thus  Senn  has  shown  that 
hydrogen  gas  inflated  into  the  colon  through  the  rectum,  under  a  pres- 
sure varying  from  one  fourth  to  two  pounds,  may  safely  pass  the  valve, 


THE  APPENDIX.  309 

enter  the  small  intestine  and  disclose  a  wound  of  the  latter  in  case  of 
stab  or  bullet  wounds  of  the  abdomen.  In  such  cases  the  incompetency 
of  the  valve  depends  upon  gradual  lateral  and  longitudinal  distension 
of  the  cfficum  whicli  mechanically  separates  the  margins  of  the  valve. 
The  same  explanation  applies  to  those  cases  of  intestinal  obstructi<jn 
where  there  is  evidence  of  the  return  of  the  contents  of  tiie  large  into 
the  small  intestine,  though  some  deny  that  it  occurs.  The  baneful 
effect  of  forced  high  injections  of  fluids  as  compared  with  that  of 
gases  probably  depends  upon  their  weight  and  lack  of  elasticity. 

Intussusception,  the  invagination  or  telescoping  of  one  part  of  the 
bowel  into  the  part  next  below  it,  generally  occurs  in  this  region  and 
is  most  common  in  childhood,  under  the  age  of  ten  years.  The  ileo- 
caecal  form  is  the  commonest  and  in  it  the  ileum  with  the  cjecum  is 
prolapsed  down  the  colon.  The  ileoccccal  valve  forms  the  apex  of  the 
intussusceptum,  or  prolapsed  mass,  and  may  even  reach  the  rectum 
and  present  at  the  anus.  Rectal  examination  should,  therefore,  always 
be  made  in  cases  where  intussusception  is  suspected.  In  a  rarer  form, 
the  ileocolic,  the  ileum  is  prolapsed  through  the  ileocecal  valve  into 
and  along  tlie  colon.  The  valve  and  caecum  retain  their  positions 
while  the  ileum  forms  the  summit  of  the  intussusceptum.  A  still 
rarer  form  is  the  colic,  where  one  part  of  the  colon  is  invaginated  into 
a  part  below,  but  the  extent  of  this  is  limited  by  the  shortness  of  the 
mesentery  of  the  colon.  The  intussusceptum  stimulates  the  enclosing 
intussuscipiens  to  painful  straining  to  stool  (tenesmus)  and  a  discharge 
of  bloody  mucus  from  the  anus  results.  Occasionally  the  intussus- 
ceptum itself  is  passed,  after  sloughing. 

On  aedion  an  intussusception  is  found  to  consist  of  ^Aree  cylinders  of 
bowel,  two  of  which  belong  to  the  prolapsed  part,  or  intussusceptum, 
and  one  to  the  containing  part,  or  intussuscipiens.  A  rare  form, 
double  intussusception,  consists  of  five  cylinders.  The  serous  surfaces 
of  the  intussusceptum  are  in  contact  with  one  another  and  are  liable  to 
form  adhesions.  The  mesentery  is  compressed  between  these  surfaces 
on  one  side,  and  this  pressure  is  apt  to  cause  venous  congestion  and 
finally  gangrene.  In  such  cases  the  invaginated  bowel  may  slough  off* 
and  be  passed  per  auum,  and  a  spontaneous  recovery  result.  Between 
the  intussusceptum  and  the  intussuscipiens  the  mucous  surfaces  are  in 
contact. 

The  appendix  (vermiformis)  is  a  narrow,  cylindrical,  blind  tube, 
which  represents  the  rudimentary  or  atrophied  lower  end  of  the  larger 
csecum  of  many  other  animals.  Even  in  the  human  fcvtus  it  is  seen 
to  be  merely  the  narrowed  extremity  of  a  capacious  crecum.  I^ike 
other  vestigial  parts  it  is  prone  to  injlainmation,  which  tends  to  cause 
its  obliteration,  a  process  which  evolution  would  appear  to  be  slowy 
bringing  about. 

Its  length  varies  between  1  and  9h  inches,  and  averoffes  about  4 
inches.  It  attains  its  greatest  length  in  early  adult  life  (20-40  yeai-s, 
Berry)  after  which  it  shrinks  somewhat.  Its  length  bears  no  relation 
to  the  size  of  the  c:ecum.     In  a  few  authentic  cases  it  has  been  reported 


310  THE  ABDOMEN. 


wanting.  When  this  condition  is  apparently  disclosed  at  an  operation 
the  fact  should  be  accepted  with  doubt,  for  its  presence  may  not  be 
apparent  without  thorough  and  careful  dissection  when  it  occupies  cer- 
tain irregular  positions.  Its  diameter  is  about  one  fourth  of  an  inch 
at  the  base  and  one  fifth  of  an  inch  at  the  apex,  but  in  old  age  it  may 
become  still  smaller.  The  longer  the  appendix  the  greater  the  diffi- 
culty, other  things  being  equal,  of  egress  of  a  solid  or  semi-solid  body 
from  the  distal  end.  With  a  long  narrow  process  the  conditions  are 
favorable  to  the  stagnation  of  its  contents,  which  predisposes  to  inflam- 
mation. 

The  length  and  the  size  of  its  lumen  is  of  more  practical  interest.  The 
diameter  of  the  lumen  varies  in  different  parts  between  that  of  a  fine 
probe  and  that  of  a  quill  and  the  average,  according  to  Ferguson,  is 
that  of  a  No.  9  sound  of  the  English  scale.  A  variable  point  is  the 
opening  into  the  ccecum,  ranging  from  a  mere  pinhole  to  a  No.  7 
catheter  (English  scale).  It  is  often  guarded  by  a  valve  or  a  promi- 
nence of  mucous  membrane  due  to  an  increase  of  lymphoid  tissue 
beneath  it.  This  is  especially  so  in  childhood  and  it  may  decrease  or 
disappear  later.  The  size  of  the  opening  here  is  important,  for  a  small 
opening  admits  fluid  fjeces  and  prevents  or  hinders  the  escape  of  semi- 
solid material.  A  valve  was  described  by  Gerlach,  guarding  the 
appendico-csecal  orifice  and  so  directed  as  to  cause  retention  of  the 
appendical  contents,  but  its  existence  is  now  doubted. 

In  about  25  per  cent,  of  cases  the  lumen  is  partially,  less  often  com- 
pletely, obliterated  commencing  with  the  distal  end.  It  is  a  physio- 
logical not  a  pathological  process.  Very  little  (4  per  cent.)  of  this 
obliteration  is  found  in  the  first  ten  years  of  life,  while  it  is  present  in 
over  50  per  cent,  of  cases  at  sixty  years.  The  obliteration  of  the 
lumen  at  its  distal  end  shortens  it.  The  lumen  may  also  be  found 
stenosed  irregularly  here  and  there,  as  the  result  of  previous  attacks 
of  inflammation  (appendicitis),  and  these  stenoses  favor  recurrence  of 
inflammation  by  interfering  with  the  proper  emptying  of  the  appendix. 
The  presence  of  obliteration  of  its  lumen  can  not  be  told  by  the 
macroscopic  external  appearance  of  the  appendix. 

The  appendix  is  held  in  position  (1)  by  the  attachment  of  its  base  to 
the  csecura  (see  caecum),  (2)  by  a  mesentery  of  its  own  (mesenteriolum). 
The  base  of  the  appendix,  and  with  it  the  appendix  itself,  varies  in 
position  with  that  of  the  caecum.  Thus  it  may  be  unusually  high  when 
the  caecum  is  partly  or  wholly  undescended  (see  caecum). 

The  mesentery  of  the  appendix  (mesoappendix  or  mesoderiolum)  is 
derived  from  the  lower  or  left  layer  of  the  mesentery,  along  a  straight 
line  a  short  distance  below  the  bowel,  and  not  quite  parallel  with  it. 
It  is  triangular  in  shape  with  its  apex  at  the  base  of  the  appendix  and 
one  side  attached  to  the  abdominal  wall,  or  the  mesentery,  the  other 
to  the  appendix,  while  the  base  is  free.  The  mesenteriolum  does  not, 
as  a  rule,  extend  to  the  tip  of  the  appendix,  but  only  about  two  thirds 
of  the  distance,  so  that  the  terminal  portion  of  the  latter  is  either 


THE  POSITION  OF  THE  APPENDIX.  311 

wholly  covered  by  peritoneum  or  it  possesses  a  narrow  fringe  of  peri- 
toneum continuous  with  its  mesentery.  The  appendical  border  of  the 
mesoappendix  is  longer  than  its  parietal  border,  which  |)artly  accounts 
for  the  tortuous  or  coiled  position  of  the  appendix,  similar  to  that  of 
the  small  intestine  and  due  to  the  same  cause. 

The  appendix  is  therefore  an  i atraperitoneal  orfjan,  wholly  covered 
by  peritoneum  except  for  a  narrow  strip  along  the  attachment  of  its 
mesentery.  Hence  inflammation  of  the  ap])endix  (append idf is)  is  an 
intraperitoneal  inflammation,  unless  walled  off*  by  adhesions  and  plastic 
exudate.  In  exceptional  casea  the  appendix  is  in  whole  or  in  part 
extraperitoneal.  Thus  it  may  lie  behind  the  Ciecum,  adherent  to  its 
wall  and  covered  by  its  peritoneum,  or  its  distal  portion  only  may  be 
extraperitoneal,  behind  the  colon,  while  its  proximal  part  is  intraperi- 
toneal, or  vice  versa.  Probably  some  of  the  cases  reported  as  extra- 
peritoneal were  really  instances  of  the  appendix  herniated  into  and 
adherent  to  the  ileocsecal  or  subcecal  fossse. 

As  a  result  of  inflammation  the  appendix  may  contract  adhesions  to 
the  visceral  or  parietal  peritoneum  with  which  it  is  in  contact.  These 
adhesions  vary  from  a  single  delicate  one  to  those  completely  binding 
down  the  entire  length  of  the  appendix.  The  latter  condition  is  not 
infrequently  found  in  operating  for  appendicitis.  I  have  found  the  tip 
separated  from  the  rest  and  only  connected  with  it  by  scar  tissue,  rep- 
resenting a  necrotic  area  of  the  tube.  In  removing  an  appendix  closely 
adherent  to  the  posterior  parietes  and  directed  inward  the  relation 
of  the  ureter  should  be  borne  in  mind.  Adhesions  to  the  ileum  may 
even  form  a  constricting  band  about  it,  or  a  bridge  may  be  formed 
beneath  which  the  small  intestine  may  be  strangulated. 

It  is  stated  (Clado)  that  in  one  case  in  ten  in  females  there  is  a  proc- 
ess of  peritoneum  passing  from  the  right  ovary  to  the  mesoappendix, 
[appendiculo-ovarian  lir/ament)  which  contains  lymphatics  and  a  small 
artery  forming  an  anastomosis  between  the  appendicular  and  ovarian 
vessels.  It  has  also  been  suggested  that  theoretically  this  anastomotic 
circulation  would  confer  a  certain  immunity  against  appendicitis,  by 
preventing  congestion  and  avoiding  gangrene. 

In  position  the  appendix,  though  tortuous,  has  a  principal  direc- 
tion from  base  to  apex,  and  is  said  to  "  point  ^^  this  way  or  that.  It 
may  point  in  any  direction  like  the  needle  of  a  compass  or  the  hands 
of  a  watch,  and  its  direction  is  sometimes  indicated  by  the  points  of 
the  compass.  A  great  number  of  observations  have  been  reported  as 
to  the  direction  of  the  appendix  by  different  observers  and  with  vary- 
ing results.  There  are  two  main  positions  of  the  aj))>endix,  one  npinird 
behind  the  ctecum,  the  other  (loirmnird  away  from  the  caecum.  Both  of 
these  main  positions  may  be  modified  by  a  lateral  deviation  to  the  right 
or  left.  Thus  the  appendix  may  point  upwards  and  to  the  right, 
and  lie  to  the  outside  of  the  cecum  and  colon,  or  it  may  point  upward 
and  to  the  left,  lying  below  the  mesentery  and  the  lower  end  of  the 
ileum.  Again  when  it  points  downward  it  may  lie  along  the  pelvic 
brim  or  project  into  the  pelvis.     The  order  of  frequency  is  (1)  retro- 


312  THE  ABDOMEN. 

caecal,  (2)  pelvic,  (3)  upward .  and  inward,  (4)  variable.  The  up- 
turned appendix  is  probably  to  be  explained  by  adhesion  of  its  dis- 
tal end  in  its  descent  from  its  foetal  position  beneath  the  liver,  the 
down-turned  appendix  by  the  absence  of  such  adhesions.  It  will  be 
observed  from  the  above  that  the  appendix  is  mostly  in  the  rigid  lumbal', 
hypogastric  or  umbilical  regions  and  more  rarely  in  the  right  iliac 
region,  though  it  usually  lies  in  part  or  wholly  in  the  right  iliac  fossa. 

Its  curved  or  sjiiral  course  is  due  to  its  short  mesentery,  or  in  other 
words  to  its  growth  between  points  fixed  at  an  early  date.  The  most 
fixed  point  is  where  the  postcsecal  branch  of  the  ileocolic  artery  joins 
it;  another  fixed  point  is  where  the  fusion  between  the  non-va«cnlar 
fold  and  the  posterior  vascular  fold  (mesoappendix)  terminates. 

The  relations  of  the  appendix  to  the  anterior  abdominal  wall  are  most 
important  for  clinical  purposes.  Both  for  diagnosis  and  operation 
McBumey's  point  is  the  one  most  commonly  used.  This  is  where  the 
line  between  the  anterior  superior  iliac  spine  and  the  umbilicus  meets 
the  outer  border  of  the  rectus,  or  2|— 3  inches  from  the  iliac  spine.  It 
lies  in  the  right  lumbar  region  and  is  a  guide  to  the  base  of  the  ap- 
pendix. In  the  vast  majority  of  cases  the  latter  will  lie  somewhere 
beneath  a.  circle  two  inches  in  diameter  having  this  point  as  its  center. 
Clado  locates  the  guiding  point  lower  down  on  a  line  with  the  anterior 
superior  iliac  spine  at  the  outer  border  of  the  rectus. 

The  walls  of  the  appendix  present  the  same  layers  as  those  of  the 
csecum  and  colon.  We  have  already  studied  the  peritoneal  covering. 
The  muscular  fibers  are  largely  replaced  by  fibrous  tissue.  The  exist- 
ence of  lonf/itudiiial  muscle  fibers  is  seen  in  the  rapid  shortening  of  the 
appendix  after  removal,  sometimes  by  one  third  of  its  length.  It  is 
spread  out  uniformly  and  not  arranged  in  bands  as  in  the  caecum  and 
colon.  The  circular  muscular  fibers  are  demonstrated  by  the  peristaltic 
movements  of  the  appendix  that  are  sometimes  observed,  and  by  their 
retraction  so  as  to  expose  the  mucosa  after  lengthwise  incisions.  This 
layer  may  form  about  one  third  of  the  thickness  of  the  appendical 
wall.  The  submucosa  is  a  thick  layer  of  dense  areolar  tissue  con- 
taining many  solitary  lymph  follicles  which  are  more  abundant  here, 
and  in  the  csecum,  than  elsewhere  in  the  large  intestine.  They  are 
also  more  numerous  in  early  life  up  to  the  twentieth  or  thirtieth  year, 
after  which  they  normally  atrophy  more  or  less.  Where  the  lumen  is 
obliterated  the  mucous  glands  of  the  mucosa  are  found  to  have  disap- 
peared, while  the  other  parts  remain.  The  mucosa  is  also  rich  in 
lymphoid  tissue.  Abundance  of  lymphoid  tissue  is  a  marked  feature 
of  the  appendix  and,  like  that  tissue  elsewhere,  it  is  prone  to  infiam- 
mation,  especially  so  in  early  life  when  it  is  in  greatest  abundance. 
This  corresponds  with  the  known  (jreater  frequency  of  appendicitis  in 
early  life. 

The  distal  end  of  the  appendix  is  thick  and  very  fibrous.  The  pres- 
ence of  faecal  concretions  in  the  lumen  of  the  appendix  is  quite  common. 
They  may  lead  to  inflammation  and  perforation  of  the  appendix,  but 
by  no  means  necessarily  cause  appendicitis,  for  we  often  find  them 


PLATE   XXXV  I 


FIG.  73. 


ILCO-COLIC  A. 


PLICA 
CAECAL       ' 


SUP.    ILEO-CAEC. 
FOSSA. 


COURSE  OF  APPENDIC.A. 
BEHIND   ILEUM 


PLIC.    ILEO_ 
.      CAEC.   ANT. 

INF.    ILEO-CAEC. 
/  FOSSA. 

MESENTERI3LUM 


APPENDIC.  A. 


SUOCAECAL   FOSSA 


Caecum,  appendix  and  end  of  ileum,  with  the 
blood  supply  and  the  neighboring  fossae.  Some- 
what   schematic.       iMerkel.) 


FOSS^  ABOUT  THE  C^CUM.  313 

post  mortem  without  sign  or  history  of  appendicitis,  yet  in  cases  of 
appendicitis  they  are  present  in  considerably  over  fifty  per  cent,  of 
cases.  Although  JorcUjn  bodies  may  be  found  in  the  appendix  they 
are  an  infrequent  cause  of  appendicitis,  as  compared  with  other  causes. 

The  swelling  of  the  mucosa  in  inflammation  tends  to  narrow  or 
entirely  close  the  lumen  at  points  already  narrowed  by  stenoses,  valves 
or  duplicatures  of  mucous  membrane,  or  by  twists  or  angles  in  the 
appendix.  As  the  appendix  is  contractile  but  not  extensible  it  is  thus 
put  to  great  strain  to  expel  its  contents.  The  pressure  on  its  wall 
causes  venous  congestion  and  adds  to  the  swelling,  and  it  is  a  question 
of  overcoming  the  obstruction  or  becoming  gangrenous.  If  a  concre- 
tion is  present  as  an  additional  obstructing  or  compressing  agent,  local 
gangrene  is  even  more  likely. 

Vessels  and  Nerves. — The  appendix  is  supplied  by  the  postcaecal 
branch  of  the  ileocolic  artery.  The  main  or  distal  branch  rearln'ii  the 
appendix  by  passing  along  the  free  border  of  the  raesoappendix, 
between  its  folds.  The  proximal  branch  passes  to  the  root  of  the 
appendix.  Exceptionally  the  artery  passes  directly  to  the  tip  of  the 
appendix  without  branching  and  then  runs  back  toward  its  base.  In 
such  a  case  the  stasis  of  its  blood  current,  from  pressure,  etc.,  before 
it  branches  within  the  submucosa  would  involve  the  entire  appendix 
iu  gangrene.  Local  blood  stasis  due  to  inflammatory  pressure  is  the 
cause  of  local  gangrene  of  the  appendix. 

The  lymphatics  enter  the  mesoappendix  where  a  lymph  node  is 
sometimes  present,  which  may  be  enlarged  or  even  broken  down  in 
appendicitis.  They  finally  pass  into  those  of  the  mesentery,  though 
occasionally,  in  the  female,  they  may  empty  into  those  of  the  ovary 
through  the  appendicnlo-ovarian  ligament. 

The  nerves  supplying  the  appendix  come  from  the  superior  mesen- 
teric plexus  which  also  supplies  the  small  intestine,  and  the  large 
intestine  as  far  as  the  splenic  flexure.  Hence  the  explanation  of  the 
pjain  in  appendicitis  being  often  referred  at  first  to  some  part  of  the 
intestines,  or  to  the  epigastric  or  umbilical  regions. 

Pericsecal  Fossae.  (Fig.  73.) — There  are  a  number  of  peritoneal 
pouches  or  fossae  in  the  ileociecal  region  which  deserve  notice  because 
into  them  the  bowel,  and  especially  the  appendix,  may  be  herniated. 

The  upper,  or  ileocolic  fossa,  lies  just  above  the  ileocolic  junction 
and  is  bounded  on  the  sides  by  the  ileum  and  the  colon,  and  in  front  bv 
the  fold  of  peritoneum  formed  by  the  passage  across  the  ileocolic  angle 
of  a  branch  of  the  ileocolic  artery.  It  opom  downward  but  is  too  high 
to  concern  the  appendix  and  is  also  less  important  than  the  following 
because  it  is  smaller  and  less  constant. 

The  ileocaecal  fossa  is  exposed  by  turning  up  the  ciecum  and  draw- 
ing down  the  appendix.  It  is  bounded  on  the  right  by  the  ciecum,  on 
the  left  l)y  the  small  intestine,  and  lies  between  the  intermediate  blood- 
less ileociecal  fold  in  front  and  the  mesoajipendix  behind.  It  njicns 
outward  and  downward,  is  almost  constant,  and  is  large,  admitting  two 
fi  ngers.     It  sometimes  is  very  deep,  extending  up  behind  the  ascend- 


314  THE  ABDOMEN. 

ing  colon  as  far  as  the  kidney  and  duodenum.  It  is  to  be  remembered 
that  the  appendix  is  often  found  in  this  fossa  which  makes  it  of  practical 
importance.  The  appendix  so  placed  may  be  thought  to  be  extra- 
peritoneal or  even  to  be  absent,  hence  we  should  look  for  this  fossa 
and  feel  behind  the  csecum  and  colon  when  the  appendix  is  not  readily 
found. 

The  subcaecal  (or  postcecal)  fossa  is  too  high  to  be  of  clinical  im- 
portance in  appendicitis  though  the  appendix  may  sometimes  be  found 
within  it,  and  be  tliought  to  be  absent.  Its  mouth  separates  the 
layers  of  the  mesocolon  at  its  lower  end. 

The  Colon. 

The  large  intestine  (Figs.  71,  72,  75  and  77),  from  the  tip  of  the 
caecum  to  the  point  where  the  mesorectum  ends*  opposite  the  third 
sacral  vertebra,  averages  four  feet  eight  inches  in  length  in  the  male, 
and  two  inches  less  in  the  female.  Its  diameter  decreases  from  above 
downwards,  measuring  1|  inches  in  the  sigmoid  flexure  and  three  inches 
in  the  csecum.  It  varies  with  the  fullness  or  emptiness  of  the  gut,  which 
is  liable  to  enormous  dilatation,  if  this  is  gradually  produced.  The 
small  intestine  may  sometimes  be  larger  than  the  large  intestine,  in 
obstruction  of  the  bowel.  In  some  cases  of  intestinal  obstruction,  situ- 
ated low  down,  the  faecal  accumulation  may  so  distend  the  colon  as  to 
displace  the  heart  and  lungs  upward  and  cause  shortness  of  breath  and 
palpitation  of  the  heart,  wliich  can  be  relieved  by  the  removal  of  the 
collection  of  faeces.  Dilatation  of  the  colon  may  occur  among  rachitic 
infants,  temporarily ;  or  it  may  be  associated  with  hypertrophy  of  the 
bowel  wall,  constipation  and  abdominal  distension.  On  the  other  hand 
the  colon  is  liable  to  be  the  seat  of  stricture.  This  tendency  increases 
from  above  downward,  being  most  common  at  the  narrowest  part,  i.  e., 
the  junction  of  the  sigmoid  flexure  and  the  rectum,  and  least  common  in 
the  ascending  colon.  The  Jiexures  of  the  colon  are  also  a  favorite  situa- 
tion for  stricture.  The  jjereussion  note  of  the  colon  is  of  a  higher  pitch 
than  that  of  the  stomach,  owing  to  the  difference  in  size  and  shape. 

The  Capacity. — The  colon  of  an  infant  six  months  old  holds  one 
pint,  that  of  a  child  two  years  old  two  or  three  pints,  and  that  of  an 
adult  nine  pints.  It  is  useful  to  remember  these  figures  in  irrigating 
the  colon.  No  attempt  should  be  made  to  force  fluid  above  the  large 
intestine.  The  irrigation  of  the  colon  empties  the  lower  ileum  by 
exciting  active  peristalsis.  The  colon  is  so  arranged  as  to  surround  the 
small  intestine  in  a  circuit  from  right  to  left. 

The  colon  is  characterized  by  (1)  three  longitudinal  bands  or  taeniae 
separating  (2)  three  rows  of  alternating  sacculi  (haustra)  and  con- 
strictions (plicae),  (3)  the  appendices  epiploicai.  Of  the  three  longi- 
tudinal bands  or  taeniae  the  one  along  the  anterior  surface  is  tlie 
longest  and  most  prominent.  As  they  start  from  the  base  of  the 
appendix  this  anterior  band  is  most  useful  in  helping  us  to  find  the 
latter.  They  measure  about  half  an  inch  in  width  and  are  about 
half  as   long  as  the  actual  length  of  the  large   intestine.     Accord- 


VESSELS  AND  NERVES  OF  THE  LARGE  INTESTINE.        315 

ingly  they  pucker  up  the  intervening  intestinal  walls  into  three  rows 
of  pouches  or  sacouli,  alternating^  with  constrictions,  and  hence  if  these 
bands  be  dissected  otf  the  gut  will  be  made  much  longer  and  of  uni- 
form contour.  They  disappear  in  the  lower  part  of  the  sigmoid 
flexure. 

Between  the  three  bands  the  longitudinal  fibers  are  sparingly  present, 
hence  the  sacculi  and  pliccc  are  made  up  of  all  layers.  The  anterior 
and  inner  of  these  bands  are  useful  in  operations  in  distinguishing  the 
large  from  the  small  intestine.  As  these  bands  are  conspicuous  only 
when  covered  by  peritoneum,  the  posterior  band,  being  along  the 
attached  border,  is  of  little  use  as  a  guide  in  the  retroj)eritoneal  lum- 
bar operations  (lumbar  colotomy,  etc.).  In  cases  of  very  great  disten- 
sion the  longitudinal  bands,  as  well  as  the  sacculi,  are  temporarily  less 
noticeable  or  even  effaced.  In  such  a  case  we  can  recognize  the  large 
intestine  by  the  presence  of  the  third  characteristic,  the  appendices  epi- 
ploicae.  These  are  small  pouches  or  tassels  of  peritoneum  containing 
more  or  less  fat  and  attached  to  the  peritoneal  covering  of  the  large 
bowel,  except  the  lower  rectum.  They  are  seen  especially  along  the 
internal  band,  and  are  most  numerous  in  the  lower  part.  They  there- 
fore afford  no  help  in  seeking  for  the  colon  through  the  loin,  along  its 
attached  or  non-peritoneal  area. 

Solitary  h/mphold  follicles  are  most  numerous  in  the  caecum  and 
appendix  and  occur  throughout  the  large  intestine.  Hernia-like  direr- 
ticula,  usually  multiple,  may  occur  throughout  the  colon  and  may  some- 
times lodge  faecal  concretions. 

The  large  intestine  is  palpable  throughout  except  at  and  near  the 
flexures  which  are  deeply  placed.  Hence,  save  at  the  flexures,  tumors 
of  the  colon,  even  when  of  moderate  size,  can  be  well  made  out,  the 
progress  along  the  colon  of  an  intussusception  can  often  be  carefully 
watched,  as  well  as  the  effects  of  injections  of  fluid  or  gas  for  its  reduc- 
tion. The  outline  of  the  colon  in  cases  of  frecal  accumulation  can  also 
be  distinctly  defined.  In  di.sfcnf<ioit  of  the  large  intestine  from  any 
cause  the  front  of  the  belly  is  comparatively  flat,  as  long  as  the  disten- 
sion is  confined  to  the  large  bowel,  while  the  two  sides  and  the  region 
just  above  the  umbilicus  are  prominent.  The  reverse  is  the  case  in 
distension  of  tlic  small  intestine. 

Vessels  and  Nerves. — The  colic  hrancJie.^  of  the  superior  mesenteric 
artery  supply  as  far  as  the  splenic  flexure  (the  end  of  the  midgut)  and 
there  anastomose  with  the  branches  of  the  inferior  inesenteric  artery 
which  supplies  the  large  intestine  below  this  point.  The  veins  enter  the 
portal  circulation. 

The  lymphatic  vessels  of  the  ascending,  transverse,  and  descending 
colon  enter  the  mesenteric  nodes,  those  of  the  sigmoid  flexure,  the 
lumbar  nodes. 

The  nerves  are  sympathetic  nerves  and  accompany  the  arteries.  Those 
M'hich  sup])ly  the  ca?cum,  ascending  colon,  and  right  half  of  the  trans- 
verse colon  come  through  the  superior  mesenteric  plexus  from  the 
coeliac  plexus;  while  those  supplying  the  left  half  of  the  transverse 


316  THE  ABDOMEN. 

colon,  the  descending  and  the  sigmoid  colon  come  through  the  inferior 
mesenteric  plexus  from  the  aortic  plexus. 

The  ascending  colon  and  descending-  colon  are  vertically  placed  in 
the  lumbar  and  hypochondriac  regions  along  the  lateral  border  of  the 
quadratus  lumborum  and  in  front  of  the  lower  part  of  the  right  kidney 
and  the  lower  part  of  the  outer  border  of  the  left  kidney.  Hence 
abscess  of  the  kidney  may  perforate  the  colon  retro-peritoneally.  The 
guide  to  the  colon  by  the  lumbar  approach  is  the  outer  border  of  the 
quadratus  lumborum  muscle,  below  the  kidney.  The  second  portion 
of  the  duodenum  is  also  behind  the  ascending  colon.  The  descending 
colon  is  more  laterally  placed  than  the  ascending,  and  hence  is  more 
accessible  through  the  loin.  The  ascending  colon  averages  five  inches 
from  the  ileocsecal  valve  to  the  under  surface  of  the  right  lobe  of  the 
liver  (impressio  colica),  on  the  right  of  the  gall-bladder.  The  descend- 
ing colon  averages  8|  inches  to  the  iliac  crest,  the  commencement  of 
the  sigmoid  loop. 

A  mesentery  is  provided  for  the  ascending  colon,  varying  from  one 
to  three  inches  in  length,  in  only  26  per  cent,  of  cases,  and  for  the 
descending  colon  in  36  per  cent.  (Treves) ;  in  the  other  74  or  64  per 
cent,  respectively,  the  peritoneum  covers  the  front  and  sides  only, 
leaving  a  wide  strip  uncovered  posteriorly.  This  strip  varies  in  width, 
averages  one  third  of  the  circumference  of  the  colon,  and  is  wider  the 
more  distended  the  colon  becomes.  It  is  here  that  the  colon  is  opened 
in  lumbar  colotomy,  hence  the  presence  of  a  mesentery  is  of  importance 
in  connection  with  this  operation,  especially  in  the  case  of  the  descending 
colon  which  is  the  portion  most  often  opened. 

Except  when  distended  the  ascending  and  descending  colons  lie 
well  back  in  the  flank,  covered  in  front  by  some  coils  of  the  ileum  and 
jejunum.  The  ascending  colon  may  be  absent  when  the  caecum  has 
not  descended,  but  the  descending  colon  shows  but  little  tendency 
to  variation  and  is  the  only  part  of  the  gut,  below  the  duodenum, 
that  retains  its  original  position  in  the  great  vertical  foetal  loop  of 
intestine. 

The  transverse  colon  averages  20  inches  in  length,  but  is  very 
variable.  As  it  is  longer  than  a  straight  line  between  its  two  ends  it 
describes  a  curve  convex  forward  and  doumivard.  As  a  rule,  it  lies 
above  the  level  of  the  umbilicus,  but  in  29  per  cent,  of  cases  it  is  below 
this  line,  and  in  some  cases  it  is  displaced  dowmvard  in  an  abrupt  V- 
or  U-shaped  bend  which  may  even  reach  the  symphysis,  while  the  two 
flexures  are  normal  in  position.  Such  bends  are  due  to  habitual  con- 
stipation or  to  congenital  causes,  according  to  Treves.  In  the  majority 
of  cases  the  central  portion  of  the  transverse  colon  is  in  the  line  sepa- 
rating the  epigastrium  from  tiie  umbilical  region. 

Relations. — Above  is  the  under  surface  of  the  liver,  the  gall-blad- 
der, the  great  curvature  of  the  stomach,  and  the  lower  end  of  the 
spleen  ;  behind  is  the  second  part  of  the  duodenum,  the  pancreas,  and 
the  transverse  mesocolon  ;  below  is  the  small  intestine,  and  in  front  the 
great  omentum  and  anterior  abdominal  wall. 


THE  SIGMOID  COLON.  317 

The  transverse  colon  always  has  a  mesentery  (inesocolon)  (Fig.  72), 
which  from  its  length  renders  this  the  inont  morahlr  portion  of  the  colon, 
hence  it  is  often  found  in  the  sac  of  an  umbilical  hernia.  Its  anterior 
surface  along  the  anterior  band  is  adherent  to  the  great  omentum,  which 
separates  it  from  the  anterior  abdominal  walls.  Through  the  omentum 
the  sacculi  of  the  colon  can  usually  be  seen.  By  raising  up  the  omen- 
tum we  expose  the  transverse  colon  adherent  to  it.  This  portion  of 
the  colon  and  the  omentum  shut  in  the  coils  of  the  small  intestine  above 
and  in  front,  respectively.  The  part  of  the  omentum  between  the 
great  curvature  of  the  stomach  and  the  transverse  colon  (f/asfrocolic 
lif/d.menf)  connects  the  two,  so  that  the  latter  moves  with  the  stomach. 
It  overlies  the  latter  when  it  is  empty,  and  is  pushed  down  by  it  when 
it  is  full.  Many  errors  in  diagnosis  are  attributable  to  fjecal  masses 
impacted  in  the  transverse  colon. 

Owing  to  the  close  relation  of  the  hepatic  flexure  and  the  right  end 
of  the  transverse  colon  with  the  gall-bladder,  ulceration  of  the  latter, 
due  to  gall-stones,  has  sometimes  extended  to  the  adherent  colon  and 
the  gall-stone  has  thus  entered  the  colon  and  been  passed  per  anum. 
It  is  often  found  stained  with  bile,  post  mortem.  If  the  gall-bladder 
and  the  jejunum  or  duodenum  can  not  be  approximated  in  cholecysten- 
terostomy,  the  anastomosis  can  be  readily  made  with  the  colon  and  the 
short-circuiting  of  the  bile  has  had  no  untoward  effect  on  the  patient's 
condition.  Hepatic  abscess  has  also  ruptured  into  and  been  discharged 
through  this  part  of  the  colon. 

The  splenic  flexure,  at  the  left  end  of  the  transverse  colon,  is  in  con- 
tact with  the  lower  end  of  the  spleen  in  the  left  hypochondrium.  It 
lies  behind  the  stomach  and  is  at  a  higher  and  more  dorsal  level  than 
the  hepatic  flexure. 

Both  flexures  of  the  colon,  deeply  placed  at  the  back  of  the  hypo- 
chondriac regions,  are  held  by  bands  of  peritoneum  passing  from  the 
hepatic  flexure  to  the  transverse  fissure  of  the  liver  (////.  hepato-eolieu/n), 
and  from  the  splenic  flexure  to  the  diaphragm  opposite  the  tenth  and 
eleventh  ribs  [lig.  phreno-colicum).  The  latter,  helping  to  support  the 
spleen,  is  also  called  the  sustrntaculum  lienis. 

The  sigmoid  colon  or  flexure  extends  from  the  level  of  the  left 
iliac  crest  to  the  third  sacral  vertebra  at  the  end  of  the  mesenteric 
attachment,  including  the  part  formerly  called  the  first  piece  of  the 
rectum.  Including  the  latter  it  forms  an  iJ-shaprd  loop  averaging 
17^  inches  long.  The  sigmoid  flexure  is  normally  found  in  great 
part  in  the  pelvis  and  not  in  the  iliac  fossa,  unless  displaced  out  of 
the  pelvis  by  its  own  distension  or  that  of  the  bladder,  rectum,  or 
female  pelvic  organs,  with  which,  as  well  as  with  the  small  intestine 
and  often  with  the  appendix  or  even  the  crecum,  it  is  in  relation  in 
the  pelvis.  If  the  mesentery  of  the  sigmoid  colon  is  unusually  short, 
the  latter  may  be  very  largely  in  the  left  iliac  fossa.  This  loop  is 
liable  to  enormous  dilatation  from  faecal  accumulation,  and  has  been 
known  to  reach  up  to  the  liver. 

In  the  newboim  the  sigmoid  loop,  usually  filled  with  meconium,  may 


318  THE  ABDOMEN. 

reach  over  to  the  right  side  owing  to  its  long  mesentery.  Under  such 
conditions  the  opening  of  this  loop  in  the  left  groin  to  establish  an 
artificial  anus,  which  is  required  in  cases  of  congenital  deficiency  of 
the  rectum,  might  be  difficult.  Yet  according  to  Curling,  it  is  found 
on  the  left  side  in  85  per  cent,  of  cases  in  young  infants. 

The  sigmoid  loop  is  provided  with  a  constant  mesentery,  1 J  to  3 J 
inches  long  from  parietal  to  intestinal  attachment,  which  connects  it 
with  the  left  iliac  fossa.  The  Ihic  of  attachment  of  this  mesentery 
crosses  the  psoas  muscle  to  reach  the  pelvic  brim  at  about  the  bifurca- 
tion of  the  left  common  iliac  vessels  and  the  sacro-iliac  articulation,  or 
a  little  above  it.  Then  it  turns  sharply  downward  and  extends  to 
the  middle  of  the  third  sacral  vertebra.  The  two  attached  extremi- 
ties of  this  loop  are  only  three  or  four  inches  apart  and  may  be  nearer 
abnormally.  Hence,  since  the  loop  itself  is  fairly  movable,  the  condi- 
tions are  such  that  we  can  easily  see  how  a  twist  (or  volvulus)  may 
occur,  as  it  does,  more  often  in  this  portion  of  the  bowel  than  in  any 
other. 

On  the  left  or  lower  aspect  of  the  root  of  the  sigmoid  mesocolon  is 
oftentimes  a  peritoneal  pouch,  the  intersigmoid  fossa,  in  which  the 
occurrence  of  at  least  two  cases  of  strangulated  sigmoid  hernia  has  been 
reported.  This  fossa  is  funnel-shapaJ ,  and  its  opening  looks  down- 
ward and  to  the  left  and  is  generally  over  the  bifurcation  of  the  iliac 
vessels.  It  is  found  by  turning  the  flexure  to  the  right.  The  fossa 
is  1  to  2J  inches  deep,  is  more  constant  in  the  infant  than  in  the  adult, 
and  is  caused  by  the  sigmoid  artery. 

The  rectal  or  colon  tube,  cannot  be  passed  beyond  the  sigmoid  loop 
under  normal  conditions,  but  the  irrigation  of  the  colon  can  be  accom- 
plished with  the  tube  in  this  loop.  In  case  of  habitual  constipation  a 
doughy  tumor  may  be  present  in  the  sigmoid  colon.  Such  tumors, 
and  those  of  other  kinds  in  this  part  of  the  bowel,  may  press  upon  the 
branches  of  the  lumbar  plexus,  such  as  the  anterior  crural  or  obturator, 
and  cause  neuralgia. 

Colotomy  may  be  performed  in  either  lumbar  region,  especially  in 
the  left,  to  establish  an  artificial  anus  when  there  is  obstruction  below. 

Lumbar  colotomy  (Amussat's  operation)  is  preferably  done  on  the 
right  side  for  it  is  nearer  the  anus.  (See  Lumbar  Region.)  The  line 
of  the  descending  colon  is  approximately  that  of  the  outer  border  of 
the  quadratus  lumborum,  i.  c,  a  vertical  line  one  half  inch  behind  the 
center  of  the  iliac  crest.  The  line  of  the  ascending  colon  is  a  little 
more  mesial.  The  obliquclij  transverse  incision,  is  placed,  with  its  center 
in  the  above  line,  below  the  level  of  the  kidney,  as  the  latter  intervenes 
between  the  colon  and  the  parietes  higher  up.  In  the  lumbar  oper- 
ation the  colon  is  opened  retroperitoneally  along  the  attached  area 
which,  in  the  empty  state,  varies  from  four  fifths  to  one  inch  in  width, 
and  in  the  distended  condition  may  reach  two  or  more  inches  (Braune). 
In  thirty-six  per  cent,  of  cases  the  descending  colon  has  a  mesentery, 
and  so  cannot  be  readily  reached  extraperitoueally.  On  the  retroperi- 
toneal  surface  neither  the  appendices  epiploices  nor  the  longitudinal 


THE  LIVER.  319 

bands  aid  us  in  distinguishing  the  colon,  for  the  latter  are  not  visible 
and  the  former  are  not  present. 

In  the  ncir-horn  the  co.sto-'iUac  space  is  very  limited  and  entirely  occu- 
pied by  tiie  kidney,  so  that,  although  the  colon  is  then  altogether  out- 
side of  the  kidney,  colotomy  is  done  in  the  inguinal  region. 

Inguinal  colotomy  (Littre's  operation)  is  the  one  most  often  prac- 
ticed in  adults  as  well  as  in  children.  The  ohlujuc  iiK-mon  is  parallel 
with  and  a  short  distance  (IJ  inches)  from  the  outer  half  of  Poupart's 
ligament,  and  may  be  intermuscular.  The  opening  is  made  in  the 
sigmoid  loop  preferably  at  its  upper  end,  for  the  danger  of  prolapse  of 
its  mucous  membrane  is  thereby  diminished.  A  transverse  spur  of 
mucous  membrane,  made  opposite  the  lower  end  of  the  opening,  pre- 
vents the  contents  passing  into  the  lower  segment  of  the  gut.  We 
easily  distinguish  the  sigmoid  loop  from  the  coils  of  the  small  intestine, 
which  often  present  themselves,  by  the  bands,  sacculi  and  appendages 
and  by  its  position. 

The  Liver. 

The  liver  (Figs.  71,  74,  75  and  77)  is  the  largest  gland  in  the  body 
and,  on  account  of  its  bulk  as  well  as  its  position,  it  is  much  r.rposcd 
to  injury.  In  size  it  averages  7  to  10  inches  from  right  to  left,  3  to  6 
inches  from  before  backward,  and  6  to  7  inches  from  above  downward, 
in  the  right  lobe.  It  is  larger  in  men  than  in  women  and,  patholog- 
ically, it  is  subject  to  great  variations  in  size  and  weight,  especiallv  to 
enlargement.  .1^  birth  it  is  relatively  much  larger  than  in  the  adult, 
reaching  below  the  costal  margin  and  as  far  to  the  left  as  the 
spleen.  Owing  to  its  size  and  weight  in  the  infant,  a  baby  is  not  laid 
on  its  left  side  soon  after  feeding,  on  account  of  the  pressure  of  the 
right  lobe  on  the  stomach.  It  is  not  until  the  sixth  or  eighth  vear  of 
childhood  that  the  anterior  border  gets  level  with  the  right  costal 
margin. 

Its  weight  is  between  45  and  60  ounces,  but  varies  according  to 
its  size  and  the  amount  of  blood  contained.  As  it  contains  nearlv  half 
a  kilogram  of  blood  it  weighs  much  more  during  life  than  at  post 
mortem.  At  birth  it  is  one  twentieth  of  the  weight  of  the  body,  in 
the  adult  male  one  fortieth.     Its  volume  is  about  95  cubic  inches. 

The  consistency  of  the  liver  hfrmcr  than  that  of  other  glands,  but 
it  is  friable.  This  fact,  together  with  its  size  and  fixity,  explains  wliv 
it  is  more  often  ruptured  from  contusion  than  any  other  abdominal 
viscus.  Free  Iiemorrharje,  often  fatal,  results  from  such  an  injurv 
because  the  hepatic  veins  are  held  open  by  the  liver  substance,  to 
which  their  walls  are  adherent,  and  there  are  no  valves  in  the  portal 
and  hepatic  veins. 

Tlie  liver  is  moulded  to  the  surrounding  organs  which  give  it  its 
shape,  that  of  an  ovoid  bevelled  off  on  its  under  part,  especially  at  the 
left  end.  When  examined  in  position  we  find  three  surfaces,  a  jtox- 
terior  resting  against  the  upper  part  of  the  posterior  abdominal  wall, 
here  formed  by  the  diaphragm  ;  an  upper  fitted  into  the  vault  of  the 
diaphragm,  and  hence  looking  forward  also  in  front ;  and  an  inferior 


320  THE  ABDOMEN. 

which  rests  upon  the  abdominal  viscera  as  upon  a  pillow.  The  left 
lohe,  large  at  birth,  diminishes  so  much  in  size  in  early  life  that  the 
falciform  ligament,  which  represents  the  division  between  the  right 
and  left  lobes  and  contains  the  round  ligament  in  its  free  edge,  is  dis- 
placed to  the  right  of  the  median  line.  Hence  median  abdominal 
incisions  pass  the  umbilicus  on  the  left  to  avoid  incising  these  liga- 
ments in  regaining  the  median  line  above  the  umbilicus. 

Position. — The  liver  lies  in  the  right  hypochondrium  and  the  epi- 
gastrium, and  extends  into  the  left  hypochondrium  a  distance  varying 
from  IJ  or  2  inches  beyond  the  left  margin  of  the  sternum  to  the  left 
mammary  line.  When  enlarged  it  extends  further  to  the  left,  under 
the  left  false  ribs  and  in  front  of  the  stomach  and  the  spleen,  as  in  the 
child.  The  bulk  of  the  liver  and  the  entire  right  lobe  is  to  the  right 
of  the  median  line. 

Throughout  its  extent  it  occupies  the  vault  of  the  diaphragm,  hence 
its  upper  limit  is  on  a  level  with  the  lower  end  of  the  mesosternum  in 
the  middle  line,  the  middle  of  the  fourth  intercostal  space  in  the  right 
mammary  line,  the  seventh  rib  at  the  right  side  and  the  upper 
end  of  the  fifth  space  in  the  left  mammary  line.  Behind  it  becomes 
superficial  below  the  right  lung,  opposite  the  tenth  and  eleventh 
thoracic  vertebrae  and  ribs,  but  its  upper  limit,  covered  by  lung,  is 
level  with  the  ninth  vertebra.  It  is  overlapped  above  by  the  thin 
margin  of  the  lung,  below  this  by  the  costophrenic  sinus.  Over  the 
latter  area  pleurae  and  diaphragm  intervene  between  the  liver  and  the 
chest  wall.  Hence,  a  penetrating  loound  in  the  area  between  the  upper 
extent  of  the  liver  and  the  lower  limit  of  the  lung^  (see  lung,  p.  218), 
or  the  line  of  absolute  liver  dullness,  may  involve  the  pleura,  right 
lung,  diaphragm,  peritoneum,  and  liver,  penetrating  four  layers  of 
pleura.  Or,  if  the  wound  be  a  little  lower,  it  may  escape  the  lung 
and  only  involve  the  two  layers  of  pleura  of  the  costophrenic  sinus, 
in  addition  to  the  diaphragm,  etc.  In  front  the  xyphoid  cartilage  and 
the  costal  cartilages,  from  the  sixth  to  the  ninth  inclusive,  and  on  the 
right  side  the  ribs,  from  the  seventh  to  the  eleventh  inclusive,  cover  the 
convex  surface  of  the  liver,  the  diaphragm  being  interposed. 

In  pjercussing  the  chest  from  above  downwards  we  find  a  region  of 
relative  liver  dullness,  where  the  liver  is  overlapped  by  lung.  This  dull- 
ness increases  as  we  pass  to  the  lower  border  of  the  lung,  where  we  reaoh 
the  line  of  absolute  liver  dullness.  This  is  at  the  sternoxyphoid  articula- 
tion in  the  median  line,  the  sixth  intercostal  space  in  the  right  mammary 
line,  the  seventh  rib  in  the  axillary  line,  and  the  lower  border  of  the 
ninth  rib  in  the  scapular  line.  The  line  of  relative  and  absolute  liver 
dullness  is  liable  to  variation  with  the  changes  in  position  of  the  dia- 
phragm in  respiration ;  in  diseases  affecting  the  extent  and  condition 
of  the  lung;  in  pleuritic  effusions;  in  abdominal  tumors,  ascites,  or 
distension  ;  and  in  variations  in  position  or  size  of  the  liver. 

The  lower  limit  of  the  normal  adult  liver  corresponds  to  that  of  its 

'In  the  fifth  or  sixth  intercostal  space  in  front,  the  sixth  at  the  side,  and  the 
seventh,  eighth  or  ninth  behind. 


POSITION  OF  THE  LIVER.  321 

anterior  border  iu  front.  In  the  median  line  it  is  at  a  point  midway 
between  the  sternoxyphoid  articulation  and  the  unihilicus ;  in  the 
mammary  line  at,  or  half  an  inch  below,  the  costal  margin  ;  on  the 
ri</ht  side  it  follows  the  tenth  and  elev^enth  ribs,  without  extending 
over  the  anterior  end  of  the  latter  as  a  rule  ;  and  behind  it  reaches  the 
lev^el  of  the  lower  end  of  the  eleventh  thoracic  vertebra.  This  would 
represent  the  lower  limit  of  the  liver  didlnesH  except  behind,  where  it  is 
continuous  with  the  dullness  of  the  lumbar  region.  If  on  the  right  side 
one  can  palpate  the  liver  below  the  tenth  and  eleventh  ribs  in  quiet 
breathing,  the  liver  is  enlarged  or  displaced  downward.  On  the  ex- 
treme right  the  lower  limit  of  the  liver  may  reach  the  level  of  the 
second  lumbar  spine.  In  the  subcostal  angle  the  liver  is  in  contact 
with  the  anterior  abdominal  walls,  and  its  loircr  limit  is  represented  by 
a  line  drawn  from  the  ninth  right  to  the  eiglith  left  costal  cartilage. 
Here  one  can  palpate  the  lower  or  anterior  margin  of  the  liver  when 
the  abdominal  walls  are  thin. 

The  liver  is  quite  movable  and  its  lower  limit  is  therefore  subject  to 
variation  from  physiological  and  pathological  causes.  Thus  owing  to 
its  intimate  relations  with  the  diaphragm  it  moves  upward  and  back- 
ward in  expiration,  downward  and  forward  in  inspiration,  so  that 
with  a  deep  inspiration  its  anterior  border  may  descend  below  the  costal 
margin  in  the  right  hypochondrium,  even  in  the  reclining  position. 
In  the  redininfi  position  the  edge  of  the  liver  is  half  an  inch 
above  the  costal  margin  on  the  right  side  in  front ;  in  the  erect  position 
it  descends  to  half  or  quarter  of  an  inch  below  this  margin. 

We  have  already  noted  the  difference  in  children  up  to  the  sixth  or 
eighth  year.  In  women  it  is  apt  to  reach  a  lower  level,  owing  to  the 
use  of  corsets,  and  in  those  who  lace  tightly  it  may  be  pushed  down 
even  to  the  iliac  fossa.  In  such  cases  of  "  corset  liver  "  the  right  lobe 
is  marked  by  a  deep  constricting  furrow,  due  to  the  pressure  of  the 
costal  margin.  In  this  furrow  the  transverse  colon  or  loops  of  the 
small  intestine  may  sometimes  be  found,  giving  rise  to  a  tympanitic 
resonance  with  dullness  above  and  below. 

In  uniform  enlargements  of  the  liver,  from  any  cause,  it  is  displaced 
downward,  where  we  can  diagnose  the  enlargement  by  percussion  and 
]ialpation.  Enlargements  of  the  liver  also  cause  a  bulging  of  the  right 
lower  ribs  and  costal  cartilages.  When,  however,  the  uppei-  part  of  the 
right  lobe  is  involved  in  abscess  or  hydatids,  the  enlargement  and  the 
area  of  dullness  extend  upward,  raising  the  diaphragm  and  encroaching 
upon  the  right  lung.  In  emphysema,  pleurisy  with  effusion,  and 
other  conditions  associated  with  distension  of  the  riglit  side  oi'  the 
thorax,  the  lower  level  of  the  liver  is  lowered.  On  the  other  hand,  in 
phthisis,  collapse  or  retraction  of  the  lung,  also  when  the  liver  is  ab- 
normally small  and  in  conditions  involving  distension  of  the  alidomen 
the  lower  level  of  the  liver  is  raised,  so  that  we  may  have  tympanitic 
resonance  over  the  lower  ?nargin  of  the  ribs. 

From  the  above  we  obtain  the  limits  between  which  the  liver  is 
accessible  to  operation.  In  the  upper  part  of  this  area  the  liver  lies 
21 


322  THE  ABDOMEN. 

deeply,  covered  by  the  lower  margin  of  the  lungs,  etc.  Above  the 
lower  limit  of  the  pleura  we  must  pass  through  the  latter  and  the  dia- 
phragm to  reach  the  liver.  This  is  necessary  when  the  trouble  affects 
the  upper  part  of  the  liver,  and  may  be  safely  done  by  suturing  the 
diaphragm  into  the  thoracic  opening  and  then  penetrating  the  dia- 
phragm. If  we  resect  the  tenth  rib  in  the  right  axillary  line  we  find 
cellular  tissue  and  diaphragm  but  no  pleura,  but  on  going  through  the 
diaphragm  we  open  the  peritoneal  cavity  and  meet  the  liver. 

The  liver  is  held  in  position  by  its  attachment  to  the  diaphragm, 
within  the  area  embraced  by  the  coronary  ligament,  by  the  latter  liga- 
ment, and  by  the  lateral  and  suspensory  ligaments.  The  latter  liga- 
ment is  of  little  or  no  service  in  suspension.  Although  the  liver  is 
firm  in  position  as  compared  with  other  intraperitoneal  organs  yet,  as 
.we  have  seen,  it  is  also  subject  to  variation  in  position.  From  the 
relaxation  of  its  ligaments,  especially  in  women  after  childbirth,  a 
"  dislocation  "  of  the  liver,  or  a  "  wandering  liver  "  may  result. 

According  to  Hasse  the  liver  is  stretched  in  insj^irafion  and  com- 
pressed in  expiration.  Doubtless  the  movements  of  respiration  stimu- 
late its  circulation,  and  probably  on  this  account  it  is  placed  between 
the  diaphragm  and  the  abdominal  walls.  Thus  a  bon  vivant  or  one 
of  active  habits  suddenly  confined  to  bed,  by  a  broken  limb,  etc.,  be- 
comes bilious  from  a  congestion  of  the  portal  circulation,  owing  to  the 
little  stimulation  it  receives  from  the  movements  of  respiration,  which 
is  now  quiet. 

Relations. — The  diaphragm  above  separates  the  upper  surface  of  the 
liver  from  the  pleural  and  pericardial  cavities.  The  latter  corresponds 
to  a  flattened  area  on  the  upper  surface  of  the  left  lobe.  The  close 
relations  of  the  liver  with  the  pleura,  lungs  and  heart,  explains  how 
hydatid  cyst  or  abscess  may  burst  into  the  pleura  or  lung,  or  even 
into  the  pericardium.  Thus  it  happens  that  pieces  of  liver,  disin- 
tegrated it  is  true,  may  literally  be  coughed  up.  Similarly  empyema 
has  been  known  to  penetrate  the  diaphragm  and  give  rise  to  a  sub- 
diaphragmatic or  an  hepatic  abscess.  The  liver  may  also  be  damaged 
when  the  right  lower  ribs  are  fractured,  owing  to  their  close  relations. 
The  broken  ends  of  the  ribs  have,  in  some  cases,  been  driven  into  the 
liver  through  the  diaphragm.  If  the  smooth  upper  surface  of  the 
liver  is  roughened  by  inflammation  its  movements  in  respiration  give 
rise  to  a  friction  sound  similar  to  that  in  pleurisy. 

The  posterior  surface  of  the  liver  rests  upon  the  right  suprarenal 
body,  to  the  left  of  this  it  is  grooved  for  the  vena  cava,  and  further 
to  the  left  it  lies  upon  the  crura  of  the  diaphragm,  with  the  various 
vessels  and  nerves  between  or  within  them,  and  the  oesophagus.  In 
case  of  great  enlargement  of  the  liver  these  structures  may  suffer  a 
certain  degree  of  compression.  The  possibility  must  be  admitted  of  a 
rupture  of  the  liver  without  tearing  the  peritoneal  coat.  Such  injuries 
are  not  often  fatal.  They  may  reach  the  surface  of  the  organ  behind, 
on  the  fairly  extensive  non-peritoneal  surface.  Here  also  a  wound  may 
occur  or  an  incision  be  made  into  the  liver  without  opening  the  peri- 


COVERINGS  AND  STRUCTURE  OF  THE  LIVER.  323 

toneal  cavity  but,  owing  to  its  position,  only  after  passing  through  the 
pleural  cavity. 

The  under  surface  of  the  rifjlii  lohe  is  in  contact  v:ith  the  upper  half 
or  two  thirds  of  the  right  kidney  and  the  suprarenal  capsuh,-,  to  the 
left  of  this  with  the  duodenum  (first  and  second  partsj,  and  in  front  of 
these  with  the  colon.  To  the  left  of  the  neck  of  the  gall-bladder  lies 
the  pyloric  end  of  the  stomach  in  relation  with  the  quadrate  lobe. 
The  loii-er  surface  of  the  left  lobe  projects  as  the  tuber  omentale,  wiiicii 
rests  upon  the  lesser  omentum,  and  in  front  of  and  to  the  left  of  this  it 
is  concave,  where  it  covers  the  lesser  curvature,  cardia,  and  ])art  of  the 
anterior  surface  of  the  stomach,  to  an  extent  varying  inversely  with 
the  fullness  of  that  organ.  It  may  even  cover  the  fundus  of  an 
empty  contracted  stomach. 

From  these  relations  we  see  that  an  abscess  of  the  liver,  after  inflam- 
matory adhesion,  may  open  inferiorly  into  the  colon,  duodenum, 
stomach  or  right  kidney,  and  also  that  an  abscess  of  or  about  the  right 
kidney  may  extend  to  the  liver.  Abscesses  of  the  liver  are  frequently 
due  to  an  inflammation,  like  dysentery,  of  some  part  of  the  alimentary 
canal  the  blood  from  which  is  returned  by  the  portal  vein,  through 
which  the  infection  is  carried.  Such  abscesses,  like  their  cause,  are 
especially  frequent  in  hot  climates  and  hence  are  called  "  tropical  ah- 
acess."  They  may  also  follow  surgical  operations  upon  the  same  parts. 
The  secondary  or  metadatic  abscesses  of  pyemia  are  frequently  found  in 
the  liver  and,  according  to  Bryant,  more  often  after  injuries  to  the 
head  than  after  other  injuries.  Tillaux  states  that  metastatic  ab- 
scesses are  superficial,  other  abscesses  deeper. 

AVe  have  already  seen  some  of  the  positions  in  which  hepatic  abscesses 
may  perforate  :  in  addition  there  may  be  mentioned  the  peritoneal  cavity 
and  the  surface  of  the  body,  after  adhesion  of  the  liver  to  the  body 
walls.  In  the  latter  instance  the  abscess  is  preferably  opened  below 
the  costal  margin  when  it  is  accessible  there. 

Hydatid  cysts  occur  more  often  in  the  liver  than  in  all  other  viscera 
taken  together.  They  may  discharge  themselves  in  the  same  manner 
as  hepatic  abscesses. 

Coverings  and  Structure. — The  liver  is  covered  by  peritoneum 
except  (1)  over  tlie  areas  between  the  layers  of  peritoneum  which 
constitute  the  ligaments  by  which  it  is  held  in  jx)sition  ;  (2)  along 
the  transverse  fissure,  where  the  lesser  omentum  is  attached  and  the 
vessels  and  ducts  enter  or  emerge  ;  and  (3)  at  the  bottom  of  the  fissure 
for  the  gall-bladder,  where  the  latter  intervenes  between  the  liver  and 
peritoneum.  Hence,  most  operations,  wounds  or  affections  of  the 
liver,  which  reach  the  surface,  must  involve  the  peritoneum. 

Beneath  the  peritoneal  coat,  or  in  place  of  it  where  it  is  wanting,  is 
a  thin  coat  of  A7>ro».s  tissue,  which  at  the  transveree  fissure  accompanies 
and  loosely  invests  the  vessels  and  ducts  throughout  the  liver.  This 
fibrous  tissue,  Glisson\<i  capsule,  forms  a  lattice-work  throughout  the 
liver,  which  is  thereby  divided  up  into  minute  lobules,  1-2  mm.  in 
diameter.     This  fibrous  lattice-work  may  become  su-ollen  in  cirrhosis 


324  THE  ABDOMEN. 

or  in  hepatitis.  In  the  latter  the  swelling  is  the  result  of  acute  in- 
flammation, and  the  liver  is  enlarged  and  tender.  In  cirrhosis  the 
swelling  is  usually  due  to  chronic  alcoholic  irritation  which,  if  con- 
tinued, results  in  hypertrophy  of  the  fibrous  tissue.  This  produces  a 
large,  hard  liver,  the  first  stage  of  cirrhosis.  The  swelling  or  hyper- 
trophy, obstructing  the  flow  of  bile  from  the  lobules,  causes  a  certain 
degree  of  jaundice,  from  the  absorption  of  the  coloring  matter,  and 
dyspepsia  is  a  constant  symptom.  The  subsequent  contraction  of  the 
new  fibrous  tissue  renders  the  liver  hard,  fibrous  and  smaller  than 
normal,  and  compresses  the  branches  of  the  portal  vein.  This  causes 
great  congestion  of  tiie  parts  which  feed  the  portal  vein,  /.  e.,  the 
stomach,  intestines,  pancreas  and  spleen.  This  results  in  varicose 
veins  of  these  parts,  from  which  serous  exudations  (ascites)  and  hem- 
orrhages may  occur,  and  aggravates  the  functional  disturbance  of  the 
digestive  tract.  The  surface  of  the  liver  becomes  rough  and  irregular 
(hobnailed  liver),  owing  to  the  contraction  of  the  fibrous  lattice-work 
which  reaches  the  surface. 

The  liver  may  be  greatly  and  uniformly  enlarged,  even  so  as  to  reach 
the  umbilicus,  in  certain  diseases  of  the  heart  and  lungs  where  the 
flow  of  blood  from  the  hepatic  veins  into  the  vena  cava  is  impeded, 
owing  to  the  congestion  of  the  right  heart.  Fatty  degeneration  is 
another  condition  which  may  cause  an  enlargement  of  the  liver,  some- 
times of  enormous  size. 

Vessels  and  Nerves. — These,  invested  by  Glisson's  capsule,  enter 
the  liver  at  the  transverse  fissure,  which  they  reach  by  ascending  be- 
tween the  two  layers  of  the  small  omentum  near  its  right  margin  and 
in  front  of  the  foramen  of  Winslow. 

The  hepatic  artery  supplies  largely  the  duct  and  vessel  walls  and 
the  fibrous  tissue  of  the  liver.  Brewer  has  called  attention  to  the  fre- 
quency of  anomalies  in  the  position  and  branching  of  this  vessel,  which, 
however,  are  seldom  of  surgical  importance.  The  portal  vein  brings 
by  far  the  greater  part  of  the  blood  to  the  liver  and  practically  all  that 
which  reaches  the  liver  cells.  The  results  of  obstruction  of  the  portal 
vein  are  seen  in  enlargement,  congestion,  varicosities,  hemorrhage, 
serous  exudation  within  (diarrhoea)  and  without  (ascites),  and  impair- 
ment of  the  function  of  the  viscera  containing  the  sources  of  the  vein. 

In  such  cases  the  anastomotic  circulation  of  the  portal  system  comes 
into  play,  viz.,  certain  of  the  superficial  branches  on  the  liver  with  the 
phrenic  veins ;  the  veins  of  the  round  ligament  with  the  epigastric 
veins  ;  the  hemorrhoidal  veins  with  branches  of  the  internal  iliac  ;  the 
gastric  with  the  oesophageal  veins  ;  and  small  branches  on  the  pancreas 
and  on  the  parts  of  the  intestine  destitute  of  a  mesentery  with  the  veins 
of  the  parietes  and  viscera  (left  kidney),  with  which  they  are  in  contact. 

Lymphatics. — The  superficial  set  on  the  posterior  half  of  the  liver 
passes  to  the  mediastinal  nodes;  on  the  anterior  half  of  the  liver  those 
on  the  right  of  the  gall-bladder  pass  to  the  lumbar  nodes  ;  those  on 
the  left  of  the  gall-bladder,  to  the  oesophageal  and  mediastinal  nodes ; 
those  about  the  gall-bladder  and  the  fore  part  ot  the  upper  surface  to 


PLATE   XXXVI  I 


Portal  rein 

Hepatic  durt 

Cystic  duct 

Hepatic  artery. 

Might  suprarenal, 

capsule 

Pyloric  orifice- 
lUghi  gaflio-epiploic 
artery 


Superior  mesenteric 
vein 


Sperniulic  iCiuLa 


kpermatic  vessels 


Injeriur  mesenteric  artery 


Viscera  of  the  upper'  part  of  the  abdomen.  The  hver 
is  lifted  up,  sho^A^ing  the  gall-bladder  and  the  upper  part 
of  the  gall-duets.     (Testut.) 


THE  GALL-BLADDER.  325 

the  nodes  of  the  small  onicntuni  near  the  transverse  fissure,  where  they 
join  the  deep  set. 

The  nerves  are  from  the  left  va(/un  and  the  caY/ac  jjUxuj<  (sympa- 
thetic). The  former  lilaments,  fewer  in  number,  pass  from  tiie  lesser 
curvature  of  the  stomach  between  the  folds  of  the  small  omentunu 
The  pain  over  the  rUjld  shoulder  in  liver  disease,  such  as  hepatitis,  et<'., 
is  a  rejlex  in  the  Hapruacroinial  nerve  due  to  the  fact  that  it  is  a 
brancli  of  the  fourth  cervical  nerve,  which  also  helj)s  t(»  form  the 
phrenic  nerve,  filaments  of  which  enter  the  liver  from  the  diaphragm. 
This  reflex  pain  is  commonly  on  the  right  side  for  the  right  lobe  is 
usually  chiefly  involved. 

Carcinoma  of  the  liver  is  a  common  condition,  not  as  a  primary  but 
as  a  secondary  or  metastatic  growth,  usually  from  the  stomach,  intes- 
tines, uterus,  or  mamnue.  These  growths  are,  as  a  rule,  multiple  and 
diffuse.  When  not  diffuse  a  tumor  of  some  size  may  be  removed,  for 
a  considerable  part  of  the  liver  may  be  removed  without  disturbance 
of  function.  Experimentally  three  fourths  have  been  safely  removed 
in  animals.  The  part  remaining  hypertrophies  and  probably  the  liver 
may  be  regenerated.  In  such  cases  the  escape  of  bile  is  not  usual, 
nor  is  it  necessarily  fatal.  Hemorrhage  can  be  controlled  by  the 
cautery  in  case  of  the  small  vessels,  the  clamp  or  suture  in  larger 
vessels  which,  as  we  have  seen,  are  held  open  by  their  connection  with 
the  tissues  in  which  they  lie. 

Varieties  are  not  common  in  the  liver.  The  left  lobe  may  be  un- 
usuallv  small  or  large,  or  a  portion  of  it  may  be  connected  with  the 
rest  bv  a  pedicle  of  peritoneum  containing  only  blood  vessels  and  so 
an  abdominal  tumor  may  be  simulated. 

The  Gall-Bladder. 

The  pear-shaped  gall-bladder  (Figs.  71  and  74)  is  3  to  4  inches  long 
by  li^  inches  wide  at  the  fundus  and  will  contain  1  to  li  ounces.  It 
may  become  greatly  enlarged  from  the  obstruction  of  the  cystic  duct  and 
some  forms  of  obstruction  of  the  common  duct,  so  as  to  contain  a  pint 
and  more  and  extend  even  below  the  umbilicus.  It  is  so  lodged  in 
the  fossa  of  the  liver  that  its  larger  end,  or  Jundm,  projects  forward, 
downward  and  to  the  right,  beyond  the  anterior  margin  of  the  liver, 
so  as  to  lie  behind  the  abdominal  wall  below  the  edge  of  the  ninth 
costal  cartilage  and  just  lateral  to  the  right  rectus  muscle.  Wlu'U 
enlarged  it  can  be  percussed  and  palpated  external  to  the  rectus 
muscle.  Such  a  tumor  moves  with  respiration  for  it  is  connected  witli 
the  liver. 

When  normal  the  gall-bladder  cannot  be  palpateil.  It  may  lie 
entirely  under  cover  of  the  liver  whose  anterior  border  is  usually 
notched  (incisura  vesicalis)  over  the  fundus  of  the  gall-bhulder.  Its 
narrow  end  or  neck  e.vlcnds  backward,  upwanl,  and  to  the  \ci\  toward 
the  transverse  fissure,  where  curving  first  to  the  right  and  then  to  the 
left,  it  opens  into  the  cystic  duct  which  continues  its  spiral  curve. 

It  is  held  in  position  by  the  attachment  to  the  liver  of  its  upper  sur- 


326  THE  ABDOMEN. 

face  by  areolar  tissue  and  of  its  under  surface  and  fundus  by  peri- 
toneum reflected  from  the  liver.  Occasionally  the  peritoneum  com- 
pletely surrounds  the  gall-bladder,  forming  a  short  mesentery  which 
suspends  it  from  the  under  surface  of  the  liver.  It  can  be  readily 
stripped  by  blunt  dissection  from  the  under  surface  of  the  liver  after 
its  peritoneal  attachment  is  divided. 

The  upper  surface  is  in  relation  with  the  liver,  the  under  surface  is 
in  contact  with  the  hepatic  flexure  of  the  colon  in  front,  and  with  the 
bend  between  the  first  and  second  portions  of  the  duodenum  and  often- 
times with  the  pyloric  end  of  the  stomach  behind,  near  the  neck.  These 
parts  are  found  stained  with  bile  after  death,  and  into  these  parts  gall- 
stones may  pass  from  the  gall-bladder  after  adhesion  and  ulceration. 
A  fistulous  tract  from  the  gall-bladder  may  also  open  on  the  surface  of 
the  abdominal  wall  and  allow  the  escape  of  gall-stones  and  bile. 

Beneath  the  partial  peritoneal  covering  the  wall  is  made  up  of 
fibrous  tissue  with  some  muscular  fibers,  principally  longitudinal,  and 
it  is  lined  with  raucous  membrane.  The  viscid  secretion  of  the  latter 
mingles  with  the  bile,  hence  the  bladder  is  more  than  a  reservoir.  Its 
secretion  is  often  the  principal  content  of  the  distended  bladder  (hy- 
drops of  the  gall-bladder),  as  when  the  cystic  duct  is  obstructed. 

Gall-stones  are  frequently  present  in  the  gall-bladder,  often  without 
giving  any  sign  of  their  presence  during  life  and  only  discovered  at 
autopsy.  They  are  formed  mainly  of  cholesterine  and  vary  from  a  flax- 
seed to  a  hen's  egg  in  size.  The  smaller  ones  may  pass  through  the 
ducts  into  the  intestine,  the  larger  ones,  if  passed,  enter  the  bowel 
through  a  fistulous  opening.  It  is  impossible  to  feel  gall-stones  through 
the  abdominal  wall,  in  fact  even  through  the  open  abdomen  one  cannot 
say  whether  a  full  gall-bladder  has  a  stone  in  it  or  not.  Though  often 
innocuous  they  may  cause  inflammation  of  the  gall-bladder.  If  its  con- 
tents are  purulent  we  call  the  condition  empyema  of  the  gall-bladder. 

The  opening  of  the  gall-bladder,  done  on  account  of  empyema,  dis- 
tension, etc.,  is  called  cholecystotomy.  Cholecystectomy  is  the  removal 
of  the  gall-bladder,  which  is  done  on  account  of  a  tumor,  gangrene,  or 
inflammation  with  obliterated  cystic  duct,  etc.  When  an  obstruction 
in  the  common  bile-duct  cannot  be  removed  we  open  the  distended 
gall-bladder  and  connect  it  with  the  jejunum,  duodenum  or  transverse 
colon  (cholecystenterostomy),  so  that  the  bile  has  a  new  route  to  the 
bowel.  Nature  sometimes  performs  the  same  operation  by  ulceration 
after  adhesion. 

Rupture  of  the  gall-bladder  as  well  as  of  the  bile-ducts  may  occur 
with  or  without  rupture  of  the  liver.  This  injury  is  more  likely  to 
occur  when  the  liver  is  enlarged  and  the  gall-bladder  distended,  and  is 
not  necessarily  fatal  if  the  bile  is  normal,  for  then  it  does  not  excite 
septic  peritonitis,  but  only  when  suppurative  processes  have  pre- 
existed in  the  gall-bladder. 

The  numerous  lymphatics  of  the  gall-bladder  pass  to  one  or  two 
small  nodes  at  the  bend  of  its  neck.  In  inflammatory  conditions  they 
may  become  so  enlarged  as  to  cause  obstruction  by  pressure. 


THE  CYSTIC  DUCT. 


327 


The  cystic  duct  (Fig.  74)  is  a  tube  U  inches  hjiuj  (1  to  3  inches, 
Joessel)  by  one  twelfth  inch  icide,  which  runa  in  the  lesser  omentum 
from  right  to  left  to  connect  the  neck  of  the  gall-bladder  with  the 
hepatic  duet,  which  it  joins  at  an  acute  angle  to  form  the  common  bile- 
duct. 

The  spiral  curve  of  the  neck  of  the  gall-bladder  and  of  the  adjoining 
part  of  the  cystic  duct  corresponds  to  the  oblique  crescentic  folda  of  its 
lining  mucous  membrane,  which  simulates  a  spiral  valve.  The  effect  of 
this  arrangement  is  to  make  it  almost  impossible  to  pass  a  probe  along 
this  duct,  unless  it  has  previously  been  distended  by  the  passage  of  a 
stone.  As  it  is  the  smallcd  pnrf  of  the  hiliury  channel,  small  stones  that 
pass  it  can  usually  quickly  pass  the  common  bile-duct.  It  is  remarkable 
what  large  stones  pass  the  cystic  and  common  ducts.  It  may  be 
greatly  enlarged  by  the  passage  of  a  stone  or  in  chronic  cases  of  ob- 
struction in  the  common  duct.  Bile  only  flows  into  the  gall-bladder 
wdien  its  flow  into  the  duodenum  is  stopped. 

Obstruction  of  the  cystic  duct  is  not  followed  by  jaundice,  for  the 
flow  of  bile  into  the  intestine  is  not  checked,  and  though  the  gall- 
bladder may  be  distended  it  is  due  to  its  own  secretion. 

The  right  and  left  bile-ducts  usually  Jom  one  another  at  an  obtuse 
angle  near  the  riejld  end.  of  the  transverse  fissure,  shortly  after  their 
exit  from  the  liver,  to  form  the  hepatic  duct,  1  to  2  inches  long  and 
one  fifth  inch  in  diameter.  The  latter  is  directed  downward  and  to  the 
right  in  the  right  margin  of  the  small  omentum. 

Fig.  75. 


VCNA     CAVA     INFERIOR 


COMMON 

DOCT 


"TTTbilc-d 

ii  il    RENAL 
lif    I  IMPRCS 


View  of  the  abdominal  viscera  from  behind,  after  removal  of  the  spinal  column  and  the  whole  of  the 
posterior  wall  of  the  abdomen,  the  peritoneum  being  left.     (After  Ills'  model.) 


328  THE  ABDOMEN. 

The  common  bile-duct  averages  about  three  inches  in  length  and 
one  fourth  inch  in  width.  Its  course  continues  that  of  the  hepatic 
duct,  lying  between  the  layers  of  the  hepatoduodenal  ligament  {i.  e., 
the  right  margin  of  the  small  omentum),  in  front  of  the  foramen  of 
Winslow  to  the  first  portion  of  the  duodenum,  behind  which  it  passes. 
Thence  it  runs  behind  and  internal  to  the  second  portion  of  the  duo- 
denum, between  it  and  the  head  of  the  pancreas.  It  is  sometimes  sur- 
rounded by  the  head  of  the  pancreas.  It  passes  obliquely  through 
the  wall  of  the  duodenum  for  three  fourths  of  an  inch,  opening  into 
the  latter  at  the  end  of  a  papilla  on  its  postero-internal  aspect,  about 
3|  inches  from  the  pylorus,  or  1|  inches  below  the  crescentic  fold  in 
the  lumen  of  the  first  bend  of  the  duodenum  (see  Duodenum). 

The  pancreatic  duct  usually /o/».s  the  common  bile-duct  in  the  duo- 
denal wall  and  below  their  junction  there  is  a  slight  dilatation  beneath 
the  mucous  membrane,  the  ampulla  of  Vater. 

The  papilla  contains  the  narrowed  part  of  the  common  duct,  hence 
stones  are  likely  to  be  arrested  just  above  it  in  the  ampulla.  The 
papilla  lies  on  a  free  edge  of  one  of  the  valvulse  conniventes,  but  is 
covered  by  a  mucous  fold  above  it,  so  that  it  is  often  difficult  to  find 
unless  we  can  express  a  drop  of  bile  or  unless  we  know  just  where  to 
look  for  it,  hence  the  value  of  the  above  measurements.  The  oblique 
course  of  the  duct  through  the  duodenal  wall,  and  perhaps  the  valvular 
folds  of  its  mucous  membrane,  described  by  Toldt,  prevent  the  back- 
ward flow  of  the  intestinal  contents.  In  their  course  the  bile-ducts  lie 
in  front  of  and  directly  upon  the  portal  vein,  and  to  the  right  of  the 
hepatic  artery.  The  lower  end  of  the  common  duct  lies  upon  the  vena 
cava,  hence  caution  is  required  in  incising  the  walls  of  the  ducts. 

The  common  duct  may  be  exposed  at  its  lower  end.  by  opening  the 
second  portion  of  the  duodenum  in  which  it  may  be  felt  by  the  finger 
as  a  cord-like  channel,  along  the  postero-internal  aspect.  By  slitting 
up  the  duct,  as  it  lies  in  the  walls  of  the  gut,  for  half  an  inch  from  its 
opening,  we  can  remove  stones  impacted  in  its  lower  end,  as  McBurney 
has  shown.  Above  this  point  we  can  expose  the  duct  by  incising  the 
peritoneum  on  the  right  of  the  duodenum,  loosening  the  latter  poste- 
riorly and  drawing  it  toward  the  median  line.  Still  higher  we  can 
expose  the  duct  by  dissecting  up  the  first  portion  of  the  duodenum  from 
its  posterior  attachment  and  drawing  it  downward.  We  may  some- 
times force  a  stone  along  the  duct,  especially  after  crushing  it  within 
the  duct  (choledolithotomy),  a  poor  practice,  or  we  may  incise  the  duct 
(choledocotomy),  remove  the  stone,  and  then  suture  the  duct  or  drain  it. 

All  the  operations  on  the  gall-bladder  and  ducts  are  pei-formed  in 
the  so-called  subhepatic  space,  bounded  by  the  liver  above  and  the  colon 
and  transverse  mesocolon  below.  The  duodenum  occupies  the  floor 
of  this  space,  and  the  pyloric  end  of  the  stomach  encroaches  upon  the 
median  side.  By  pushing  the  liver  up  and  retracting  the  transverse 
colon  down,  and  perhaps  pushing  the  stomach  to  the  left,  we  get  room 
for  exploration  and  operation,  though  all  the  biliary  passages  lie  at  an 
uncomfortable  depth.     As  the  result  of  inflammatory  adhesion   the 


PLATE   XXXVI  I  I 


FIO.  76. 


LOWER   LIMIT  OF  LUNG 


Outline   of  lower   half  of   bony   thorax,  showhig   the 
position  of  the  spleen.     (Merkel.) 


LOWER  LIMIT 
OF  lung" 


)WER  LIMIT !— , 

OF  PLEURA 


EXT.  ARCUAT.  LIG. 

ANO  LOWER  BORDER' 

OF  DIAPHRAGM. 


EXT.  BORDER  OF 
ERECT.  SPIN.  M. 


EXT.  BORDER  OF 
QUAD.  LUMB,  V.. 


Outline  of  the  abdominal  viscera  from  behind, 
showing  their  relation  to  one  another,  the  lower  ribs 
and  the  vertebrae.  Kidneys  in  black,  spleen  in  red. 
liver  in  yellow,  duodenal  loop  and  colon  in  blue. 
(Merkel. ) 


THE  SPLEEX.  329 

subhepatic  space  may  be  obliterated,  which  greatly  increases  the  diffi- 
culties of  operation. 

When  a  stone  becomes  impacted  in  one  of  the  ducts  the  muscle  fibers, 
which  are  mostly  circular  in  the  duct,  make  a  violent  spasmodic  effort 
to  dislodge  it.  This  may  be  partly  successful,  the  stone  may  pass 
on  a  little  ways  and  again  become  impacted,  and  so  on.  Thus  attacks 
of  hepatic  or  biliary  colic  succeed  one  another  until  the  stone  is  passed 
or  becomes  more  firmly  impacted.  A  stone  impacted  in  the  common 
duct  may  partly  or  wholly  stop  the  flow  of  bile  into  the  duodenum. 
In  the  latter  case  the  ducts  above  the  obstruction  Ijecome  distended, 
the  stools  become  clay-colored  and  the  patient  jaundiced.  The  gall- 
bladder, curiously  enough,  is  rarely  distended  but  is  usually  contracted 
in  such  cases.  Obstruction  may  also  follow  pressure  from  without,  as 
from  a  tumor  of  tlie  head  of  the  pancreas  or  the  stenosis  of  the  duct 
due  to  inflammation  of  its  mucosa. 

Varieties. — The  gall-bladder  may  be  constricted  transversely  or 
longitudinally,  or  may  even  be  absent,  in  which  case  the  hepatic  duct 
is  usually  dilated  before  opening  into  the  intestine. 

The  Spleen. 

Position.  (Figs.  71,  76  and  77.; — The  spleen,  the  largest  and 
most  important  of  the  ductless  glands,  lies  in  the  dorsal  part  of  the  left 
hypochondriac  and  epigastric  regions,  between  the  concavity  of  the 
diaphragm  behind  and  to  the  left,  the  fundus  of  the  stomach  in  front 
and  to  the  right,  the  left  kidney  and  the  splenic  flexure  of  the  colon 
internally  and  below.  Its  long  axis  corresponds  with  that  of  the  tenth 
rib,  and  it  extends  between  the  eighth  and  eleventh  ribs.  The  upper 
or  larger  end  extends  to  within  l\-2  inches  of  the  median  line,  or 
within  one  inch  of  the  vertebral  column,  and  sometimes  touches  the 
latter.  It  is  on  a  level  with  the  tenth  thoracic  vertebra  or  the  ninth 
thoracic  spine.  Its  lower  end,  which  lies  further  downward,  outward  and 
forward  on  a  level  with  the  first  lumbar  spine,  about  reaches  the  mid- 
axillary  line,  but  normally  does  not  extend  beyond  the  left  costo- 
clavicular line  {i.  e.,  from  the  left  sternoclavicular  joint  to  the  tip  of 
the  left  eleventh  rib). 

The  spleen,  therefore,  lies  under  cover  of  the  bony  thorax  and  can- 
not be  palpated  when  normal.  Its  position  is  affected  by  respiration, 
though  not  so  much  as  that  of  the  liver,  for  the  diaphragm  exercises 
less  influence  upon  it.  It  sinks  somewhat  in  inspiration,  pleural 
effusions,  and  emphysema  ;  it  rises  in  expiration,  and  is  pushed  up  by 
ascites  and  abdominal  tumors.  When  much  enlarged  it  disphiees 
upward  the  heart  and  left  lung,  causing  palpitation  and  shortness  of 
breath. 

The  spleen  is  held  in  position  by  peritoneal  folds  containing  fibrous  tis- 
sue strands  ;  i\\Q  phreno-Kjilrnii'  ligament  (lig.  suspensorium  lieuis)  from 
the  left  cms  of  the  diaphragm,  and  the  phreno-colic  ligament  (sustentacu- 
lum lienis).  The  latter,  passing  from  the  diaphragm,  opposite  the  free 
ends  of  the  tenth  and  eleventh  ribs,   to  the  splenic   flexure  of   the 


330  THE  abdome:s. 

colon,  forms  a  pocket  for  the  spleen  in  the  new-born  and  holds  it  up 
by  supporting  the  colon  on  which  it  rests.  If  the  latter  ligament  be- 
comes relaxed  the  spleen  is  displaced  downward  and  lies  more  vertically. 
Earely  the  spleen  is  found  low  down  in  the  abdomen  or  even  in  the 
pelvis.  Such  a  "  imndering  spleen"  is  liable  to  atrophy  from  a  tor- 
sion of  the  vessels  in  the  lengthened  pedicle,  and  it  may  cause  so 
much  pain  from  stretching  of  the  vessels  and  nerves  as  to  require 
removal. 

The  gastrosplenic  omentum  affords  but  little  fixation  to  the  spleen, 
more  to  the  fundus  of  the  empty  stomach.  When  the  stomach  is 
empty  this  omentum  lies  transversely,  while  the  full  stomach  separates 
the  two  layers  to  cover  its  distended  fundus.  Thus  the  full  stomach 
comes  in  direct  relation  with  the  spleen. 

As  to  size,  the  spleen  varies  more  than  any  other  organ.  Its  nor- 
mal  average  in  the  adult  is  about  5  inches  in  length,  3  in  width,  and 
IJ  in  thickness;  also  170-195  gms.  in  weight  in  the  cadaver,  and 
about  i  more  when  filled  with  blood.  It  is  relatively  large  in  child- 
hood and  atrophies  in  old  age.  It  is  enlarged  during  digestion,  in 
cases  of  congestion  of  the  portal  vein,  in  malarial  poisoning,  leukse- 
mia,  and  infectious  diseases.  It  may  attain  such  size  as  to  reach  the 
pelvis  and  nearly  fill  the  whole  abdomen,  so  as  to  be  mistaken  for  an 
ovarian  or  uterine  tumor,  but  unlike  tumors  of  the  kidney  it  is  not 
covered  in  front  by  intestines.  Its  w^eight  may  equal  20  lbs.  or 
more.  In  the  child  the  enlarged  spleen,  in  its  earlier  stages,  is  said 
to  encroach  upon  the  thoracic  cavity  more  than  in  the  adult,  owing  to 
the  firmer  support  of  the  phreno-colic  ligament  in  the  young.  More 
rarely  the  spleen  is  enlarged  on  account  of  abscess,  cysts  (especially 
hydatids)  and  malignant  tumors.  In  cases  of  enlargement  its  limits 
may  be  determined  by  palpation  even  better  than  by  percussion.  The 
normal  notching  of  its  sharp  anterior  border  helps  to  identify  the  spleen 
when  enlarged  below  the  costal  margin.  There  are  not  infrequently 
mpernmaerary  spleens  partly  or  entirely  detached  from  the  mother 
organ,  and  in  the  latter  case  situated  usually  in  the  gastrosplenic  or 
great  omentum,  or  in  the  transverse  mesocolon.  On  the  other  hand 
the  spleen  may  be  congenitally  w^anting. 

Owing  to  its  soft  consistence  it  is  very  friable  and  therefore  liable  to 
rupture.  But  this  accident  is  not  common  with  the  normal  spleen, 
owing  to  the  protection  afforded  by  its  position  and  relations  and  the 
fact  that  it  is  swung  up  by  and  rests  upon  elastic  peritoneal  folds. 
When  enlarged  the  spleen  is  more  readily  ruptured,  often  by  quite 
insignificant  violence  without  trace  of  injury  externally,  and  even  by 
muscular  violence,  of  which  several  cases  are  recorded.  The  spleen  may 
be  lacerated  in  severe  fractures  of  the  left  ninth,  tenth  or  eleventh  ribs, 
by  the  broken  end  of  a  rib  driven  through  the  diaphragm,  or  by  the 
direct  violence  which  produced  the  fracture.  Owing  to  the  extreme 
vascularity  of  the  spleen  its  rupture  is  often  fatal  from  hemorrhage. 
The  recovery  of  cases  of  limited  wounds  and  gunshot  injuries  of  the 
spleen  is  attributed  to  the  contraction  of  the  muscle  fibers  of  its  cap- 


RELATIONS  OF  THE  SPLEEX.  331 

sale,  which  narrows  the  opening  and  favors  the  arrest  of  hemorrhage 
bv  coagulation  of  the  blood. 

Relations.  (Figs.  72,  74  and  75.) — The  convex  dorsal  or  phrenic 
surface,  directed  backward,  upward  and  to  the  left,  is  in  contact  icith 
the  diaphragui.  It  is  separated  from  the  parietes  at  its  lower  end  bv  the 
diaphragm,  liigher  up  by  the  diaphragm  and  the  costophrenic  sinus  of 
the  pleura  and  above  by  the  diaphragm  and  the  lower  edge  of  the  lung. 
These  relationships  explain  the  cases  where  wounds  of  the  spleen  are 
combined  with  those  of  the  lung  and  pleura  and  the  rare  cases  where 
abscess  of  the  spleen  has  perforated  through  the  diaphragm  into  the 
left  pleural  cavity.  The  concave  gastric  surface,  directed  forward  and 
inward,  is  in  contact  with  the  fundus  of  the  stomach  when  the  latter  Ls 
full,  but  not  when  it  is  empty  and  contracted.  The  tail  of  the  pan- 
creas reaches  its  lower  end.  The  upper  end  and  the  upper  half  of 
the  outer  border  of  the  left  kidney  is  in  contact  with  the  renal  surface, 
wliich  looks  inward  and  downward.  At  the  lower  and  oxder  end  of  the 
spleen  is  a  triangular  area  which  rests  upon  the  splenic  flexure  of  the 
colon  and  the  phrenocolic  ligament. 

These  relations  explain  the  difficulty  in  percussing  the  normal  or 
slightly  enlarged  spleen.  Its  upper  end,  above  the  tenth  rib,  is  over- 
lapped by  the  lung  and  covered  by  the  thick  muscles  of  the  back. 
Below  the  lung  it  rests  against  the  kidney  and  colon  so  that  its  limit 
cannot  be  defined  by  percussion,  especially  if  the  colon  is  filled  with 
faecal  masses.  The  difficulty  is  still  further  increased  if  the  stomach  is 
filled  with  food.  The  lower  and  outer  end  is  the  only  part  determinable 
by  percussion,  and  even  here  faecal  masses  in  the  colon  may  interfere. 
The  area  of  splenic  dullness  may  disappear  in  emphysema  and  pleuritic 
efFusions ;  and  it  varies  in  respiration  as  well  as  with  any  change  in 
position  or  size  of  the  organ. 

The  spleen  is  entirely  covered  with  peritoneum  except  about  the  hilum, 
a  row  of  depressions  on  the  gastric  surface  just  in  front  of  the  inner 
border,  where  the  vessels  enter  or  emerge  between  the  two  layers  of 
peritoneum  forming  the  gastro-splenic  omentum.  The  latter,  with  the 
contained  vessels,  forms  the  pedicle  which  requires  to  be  carefully 
ligated  in  extirpation  of  the  spleen  (splenectomy). 

Of  the  vessels  the  tortuous  artery  is  very  large  for  the  size  of  the 
spleen  and  renders  it  a  very  vascular  organ.  It  also  sends  brandies 
to  the  pancreas  and  to  the  fundus  of  the  stomach  (vasa  brevia  in  the 
gastro-splenic  omentum).  The  splenic  vein  goes  to  form  the  ]X)rtal 
vein  and  is  double  the  size  of  the  artery.  It  lies  below  the  artery  and 
is  much  straighter  than  it.  The  lyntjjhatic.^  collect  in  nodes  at  the 
hilum,  from  which  vessels  pass  to  the  thoracic  duct. 

Although  the  spleen  is  rich  in  blood  vessels  it  is  poor  as  to  nerve 
supply  which  comes  from  the  solar  plexus  and  the  right  pneumogastric. 

Extirpation  of  the  spleen  [sjilenectomy)  is  indicated  and  has  been  done 
for  wounds  and  ruptures,  cysts  and  abscess,  simple  and  malarial  hyper- 
trophies and  "  wandering  spleen."  For  the  latter  condition,  .<?/>/«';io- 
pexis  has  also  been  advised  and  performed  by  stitching  the  spleen  in 


332  THE  ABD031E^. 

place  and  forming  a  new  peritoneal  shelf  for  it.  Splenectomy  for 
leukaemic  enlargement  has  been  practiced  but,  owing  to  its  uniform 
fatality,  is  not  now  considered  justifiable.  In  splenectomy  a  free 
incision  is  made  along  the  left  costal  border,  or  sometimes  in  the  median 
line  or  in  the  left  semilunar  line.  The  most  important  and  difficult 
feature  is  the  securing  and  ligation  of  the  pedicle,  the  gastrosplenic 
omentum,  with  the  very  large  vessels  contained.  If  too  much  traction 
is  made  there  is  danger  of  tearing  these  vessels,  especially  the  splenic 
vein. 

The  Pancreas. 

The  pancreas  (Figs.  71,  72,  74  and  75)  is  a  retroperitoneal  organ 
and  lies  deeply  in  the  epigastric  and  left  hypochondriac  regions,  behind 
the  stomach  and  lesser  peritoneal  sac  and  between  the  duodenum  on 
the  right  and  the  spleen  on  the  left.  Hence  it  is  not  easily  accessible 
for  surgical  or  diagnostic  purposes.  It  crosses  the  median  line  in 
front  of  the  first  and  second  lumbar  vertebrae,  from  2^  to  5  inches 
above  the  umbilicus.  Although  it  has  been  ruptured,  wounded  or 
even  herniated  (in  some  very  rare  cases  of  diaphragmatic  hernia), 
these  conditions  never  affect  the  pancreas  alone,  but  only  in  connection 
with  similar  injuries  of  other  neighboring  viscera.  It  may  sometimes 
be  felt  on  deep  pressure  in  emaciated  subjects  when  the  stomach  and 
colon  are  empty. 

It  riiai/  be  reached  by  raising  the  omentum  and  transverse  colon, 
dividing  the  lower  layer  of  the  transverse  mesocolon  and  elevating 
the  upper  layer,  which  covers  the  pancreas  ;  or  by  dividing  the  gastro- 
colic or  gastrohepatic  ligaments,  and  then  the  peritoneum  at  the  back 
of  the  lesser  peritoneal  sac. 

Although  it  has  relations  with  many  most  important  structures, 
many  of  these  relations  are  of  no  surgical  interest.  The  lower  end  of 
the  common  bile-duct  lies  in  a  groove,  often  a  canal,  in  the  head  of 
the  pancreas.  Hence  carcinoma  or  chronic  inflammatory  enlargement 
of  the  head  of  the  pancreas  may  so  press  upon  the  duct  as  to  partly  or 
completely  occlude  it  and  cause  persistent  jaundice.  This  part  of  the 
pancreas  has  the  vena  cava,  vena  portae,  aorta,  and  superior  mesenteric 
vessels,  etc.,  behind  it,  so  that  removal  of  tumors  here  situated,  unless 
encapsulated,  is  almost  impracticable,  although  it  has  been  done.  The 
pancreas  also  lies  in  front  of  the  left  renal  vein  and  the  right  renal 
vessels,  and  its  tail  is  in  front  of  the  hilum  and  the  middle  or  upper 
part  of  the  left  kidney.  These  relations  are  to  be  borne  in  mind  in 
nephrectomy. 

The  pylorus  of  the  full  stomach  lies  in  front  of  the  neck  of  the  pan- 
creas. The  splenic  vein  and  artery  lie  in  grooves,  respectively  behind 
and  above  its  upper  border.  The  tail  of  the  pancreas  touches  the 
spleen  at  its  lower  end  and  at  the  dorsal  and  lower  part  of  the  gastric 
surface.  In  operations  on  the  pylorus  or  the  spleen  it  is  important  not 
to  wound  the  pancreas  or  to  include  it  in  the  ligature,  for,  according  to 
Billroth,  the  secretion  of  the  pancreas  may  perhaps  interfere  with  the 
healing  of  the  wound  by  dissolving  the  cicatrix  and  lead  to  an  obstinate 


THE  KIDNEYS.  333 

fistula.  Perforating  ulcers  of  the  rear  wall  of  the  stomach  may  result 
in  adhesion  of  the  latter  to  the  pancreas  or,  rarely,  in  abscess  of  the 
pancreas.  A  biliary  calculus  lodged  just  beyond  the  ampulla  of  Vater, 
or  in  the  papilla,  obstructs  the  pancreatic  duct,  which  usually  joins  tlie 
common  bile-duct  in  tiie  duodenal  wall  just  above  the  ampulla.  An 
accessory  communicating  duct,  iJw  dud  of  Santorini,  in  the  head  of 
the  organ  above  the  pancreatic  duct,  may  open  separately  into  the 
duodenum  an  inch  or  so  above  the  papilla  and  afford  an  outlet  for  the 
pancreatic  secretion  in  such  cases. 

Ci/.its  occasionally  occur  in  the  pancreas,  the  result  of  ol^struction  of 
the  duct  or  other  causes.  Such  cysts  apjiear  in  the  epigastrium  above 
the  umbilicus,  usually  below  the  stomach,  which  is  pushed  up,  and 
above  the  transverse  colon.  They  require  opening  and  drainage  of 
the  fluid,  which  may  be  under  great  pressure.  Acute  inflammation  of 
tlie  pancreas  (pancreatitis)  may  involve  hemorrhage,  necrosis  or  abscess 
of  the  pancreas,  fat  necrosis  or  general  peritonitis,  and  demands  opera- 
tion. Chronic  pancreatitis  may  obstruct  the  common  bile-duct  by 
pressure  and  also  calls  for  operative  treatment. 

The  Kidneys. 

Position.  (Figs.  71,  77  and  78.; — The  kidneys  lie  retroperitoncally 
and  are  deeply  placed,  one  on  either  side  of  the  spine,  so  that  they 
cannot  be  palpated  when  normal  in  size  and  position,  except  the  lower 
end  of  the  right  kidney  in  some  cases.  They  approach  the  surface  most 
nearly  below  the  twelfth  rib  and  to  the  outer  side  of  the  erector  spinas 
muscle.  When  palpable  they  may  be  best  felt  from  in  front  just  below 
the  costal  margin  and  external  to  the  rectus  muscle,  while  the  other 
hand  presses  forward  from  behind  below  the  last  rib. 

The  vertical  line  perpendicular  to  the  middle  of  Poupart's  ligament, 
which  marks  off  the  regions  of  the  abdomen,  cuts  the  kidney  longi- 
tudinally so  that  one  third  of  it  lies  to  tlie  outer  side  and  two  thirds 
to  the  inner  side.  The  infracostal  plane,  connecting  the  lowest 
points  of  the  tenth  costal  cartilages,  cuts  the  lower  ends  of  tiie  kid- 
neys, though  it  is  not  infrequently  above  the  lower  end  of  the  left 
kidney.  Hence  the  kidneys  are  found  in  the  following  regions,  epigas- 
tric, hypochondriac,  umbilical,  and  lumbar,  but  mainly  in  the  two 
former  and  little  or  none  in  the  lumbar  region,  wiiere  tiiey  are  often 
incorrectly  thought  of  as  being.  In  the  female  and  the  child  they  are, 
as  a  rule,  slightly  loioer,  often  reaching  the  level  of  the  iliac  crest. 
In  the  male  also  they  are  not  infrequently  lower  than  normal.  lu  most 
cases  the  rigid  hidney  is  about  half  an  inch  loirn-  than  the  left,  espe- 
cially at  the  upper  end,  but  excej)tions  are  common.  With  these 
modifications  in  mind  we  may  say  that  the  kidneys  corre-^poud  to  the 
last  thoracic  and  the  first  two  or  three  lumbar  vertebne.  The  left 
kidney  extends  from  the  level  of  the  lower  end  of  the  eleventh  thoracic 
spine  to  a  little  below  the  second  lumbar  s]>ine. 

The  position  of  the  kidney  may  be  indicated  posteriorly  by  a  paral- 
lelogram whose  upper  and  lower  ends  are  drawn  horizontally  outwards 


334  THE  ABDOMEN. 

from  the  two  latter  points,  about  4  or  4|  iuches  apart,  while  the  sides 
are  drawn  vertically  1  inch  and  3|  inches  from  the  spine  (Morris).  The 
outer  border  therefore  reaches  a  point  3|  to  4  inches  from  the  lumbar 
spines.  The  twelfth  rib  crosses  the  position  of  the  kidney  in  such  a  way 
that  one  third  or  more  of  the  organ  is  above  it,  under  cover  of  the  thoracic 
wall.  This  rib  is  sometimes  resected  in  operations  upon  the  kidneys  in 
order  to  gain  more  room,  and  Avith  care  it  may  be  done  without  risk 
to  the  pleura.  But  in  one  case,  with  rudimentary  twelfth  rib,  the 
eleventh  rib  was  removed  for  the  twelfth,  the  pleura  opened  and  death 
resulted.  The  eleventh  rib  overlaps  the  upper  pole  of  the  left  kidney 
and  the  tips  of  the  transverse  processes  of  the  first  and  second  lumbar 
vertebrae  overlap  the  mesial  border  of  both  kidneys.  The  lotrer  end  of 
the  right  kidney  is,  on  the  average,  1-1 1  inches  above  the  iliac  crest 
behind  and  the  level  of  the  umbilicus  in  front,  hence  the  kidneys  lie 
higher  than  often  supposed. 

1)1  front  the  upper  ends  of  the  kidneys  about  correspond  to  the  inter- 
chondral  articulation  of  the  sixth  and  seventh  costal  cartilages,  and  they 
extend  downward  from  here  4  or  4|  inches,  i.  e.,  to  an  inch  or  so  above 
the  umbilicus.  The  shortest  distance  between  the  two  kidneys  above  is 
about  2|  inches.  The  hilum  is  about  two  inches  from  the  median  line 
and  opposite  the  first  lumbar  spine.  Owing  to  the  oblique  position  of 
the  kidneys,  the  axis  sloping  downwards  and  outwards,  the  loioer  pole 
of  the  organ,  or  the  center  of  the  lower  end,  is  one  half  or  one  inch 
further  from  the  median  line  than  the  upper  pole,  which  is  two  inches 
from  it.  The  inner  border  of  the  right  kidney  lies  very  close  to  the 
vena  cava,  that  of  the  left  kidney  an  inch  or  more  from  the  aorta. 

The  slight  downward  movement  (one  half  inch,  Holden)  of  the  kid- 
neys in  inspiration  or  their  lower  position  in  accumulations  in  the 
pleura  are  accounted  for  by  the  relation  of  the  kidneys  to  the  dia- 
phragm and  to  the  organs  like  the  spleen  and  liver,  which  move  with 
it.  The  kidneys  also  lie  slightly  lower  (about  one  half  inch)  in  the 
standing  than  in  the  reclining  position. 

Posterior  Relations.  (Fig.  78.) — The  kidneys  lie  upon  the  dia- 
phragm above  and  the  quadratus  lumborum,  transversalis  and  outer 
border  of  the  psoas  below,  the  muscles  being  covered  by  their  respec- 
tive fasciae.  Intervening  between  the  quadratus  muscle  and  the  kidney 
are  the  last  thoracic,  iliohypogastric  and  ilioinguinal  nerves  and 
the  first  lumbar  vessels,  all  of  which  pass  obliquely  outward  and 
downward  and  may  be  met  with  in  exposing  the  kidneys  from  behind. 
The  last  thoracic  nerve  indicates  the  lower  end  of  the  diaphragm,  above 
which  it  is  not  safe  to  incise.  The  area  of  contact  with  the  diaphragm 
is  larger  on  the  left  than  on  the  right  side,  owing  to  the  higher  position 
of  the  left  kidney.  But  on  both  sides  it  is  of  great  importance,  as 
the  kidney  is  here  in  close  relation  to  the  pleura,  whose  lower  limit 
extends  nearly  horizontally  from  the  lower  border  of  the  twelfth 
thoracic  vertebra,  meeting  the  twelfth  rib  about  3|  inches  from  the 
median  line  and  the  eleventh  rib  about  2  inches  further  laterally.  If 
a  marked  hiatus  diaphragmaticus  exists  above  the  lig.  arcuatum  ext. 


PLATE  XXX  IX 


FIG.  78. 

OESOPHAGUS 


INT.    ARCUATE 
LIGAMENT 


^\.  ELEVENTH 


V-v  ^\\*            RIB 

/       \ 

/         \    *    ^  HIATUS,    DIAPHRA 

'             ,     *  MATICUS,    SHOV 


ING    PLEURA 


EXTERNAL    ARCU- 
ATE    LIGAMENT 


TWELFTH   THORA- 
CIC   NERVE 


Vi^       I  LIO-HYPOGAS- 
TRIC    NCRVe 


I  LIO-INGUINAL 
NERVE 


Position  of  ihe  kidney  witin  reference  to  tiie  posterior' 
abdonninai  wall.  The  dotted  i-ed  line  r-epresents  the 
position    of   the    lelt    kidney.       (Testut.) 


RELATIONS  OF  THE  KIDNEYS.  335 

between  the  vertebral  and  costal  portions  of  the  diaphragm,  the  kid- 
ney may  come  in  coiddd  irith  the  s-iihjjleunil  tissue.  The  re/fifion.shij/ 
of  the  kidneij  and  pleard  explains  (1)  the  frequency  of  perforation  of 
perinephritic  abscesses  into  the  pleura,  especially  on  the  left  side,  a 
serious  complication,  and  (2)  the  danger  of  opening  the  pleura  in 
operating  upon  the  kidney,  especially  if  the  last  rib  should  be  rudi- 
mentary and  the  eleventh  rib  be  mistaken  for  it,  from  failure  tf»  ef)unt 
the  ribs.  As  a  rule  the  incmon  may  be  safely  carried  just  i)elo\v  the 
lower  border  of  the  twelfth  rib,  but  it  must  be  remembered  that  some- 
times that  part  of  the  pleura  which  extends  below  the  twelfth  rib 
reaches  beyond  the  lateral  margin  of  the  quadratus  lumborum,  under 
otherwise  normal  conditions.  A  thirteenth  rib  would  contract  the 
space  available  for  the  lumbar  approach  to  the  kidneys. 

The  anterior  relations  (Figs.  72,  74  and  75)  of  the  two  kidneys 
are  diHercnt.  In  front  of  the  right  kidney  is  the  liver  (renal  impres- 
sion) in  the  upper  half,  the  ascen<ling  colon  in  the  lower  half,  and  the 
second  portion  of  the  duodenum  along  the  inner  margin.  The  follow- 
ing viscera  lie  in  front  of  the  left  kidney  in  the  positions  indicated,  the 
stomach  in  the  upper  third,  the  splenic  vessels  and  pancreas  in  the 
middle  third,  and  the  descending  colon  in  the  outer  part  of  lower 
third  ;  while  along  the  upper  half  of  the  outer  border  lies  the  spleen. 
Abscess  of  or  about  the  kidney  may  involve  the  other  organs  in  con- 
tact, such  as  the  liver,  spleen,  or  pancreas ;  or  perforate  and  open  into 
the  colon,  duodenum,  or  stomach.  The  above  relations  are  also  im- 
portant to  remember  in  nephrectomy.  In  the  case  of  fHinor.^  or  other 
enlargements  of  the  kidney  the  resonant  colon  is  pushed  forward  in 
front  of  them,  hence  there  is  tympanitic  resonance  in  front.  Tumors 
of  the  kidney  have  but  little  movement  with  respiration  and  they  are 
rounded  and  not  notched  like  the  anterior  margin  of  the  spleen.  The 
position  of  the  kidneys  under  the  spleen  or  liver  ex])lains  how  enlarge- 
ment or  dislocation  of  these  organs  displace  the  kidneys  downward. 

Relations  of  the  Kidney  to  the  Peritoneum. — The  above  viscera 
in  relation  to  the  anterior  surface  of  the  kidney,  with  the  exception 
of  the  liver  and  stomach,  intervene  between  the  kidney  and  the  peri- 
toneum, so  that  the  latter  covers  only  a  limited  area  of  the  anterior 
renal  surface.  This  area  is  somewhat  greater  in  the  right  kidney 
than  in  the  left.  The  peritoneum  covering  the  left  kidney  is  derived 
from  that  of  both  the  lesser  and  greater  peritoneal  sacs.  The  perito- 
neal covering  is  readily  stripped  from  the  kidney.  According  to 
Lange,  the  distance  between  the  lateral  edge  of  the  quadratus  muscle, 
internally,  and  the  point  where  the  peritoneum,  external  to  the  kidney 
touches  the  parietes  is  considerable  but  is  less  on  the  left  side  by  at 
least  one  centimeter.  It  is  in  this  sjxice  that  we  expose  the  kidney  by 
the  lumbar  incision.  The  peritoneum  forms  a  complete  covering, 
mesonephron,  in  the  congenital  variety  of  floating  kidney.  The  posi- 
tion of  the  kidney  behind  the  peritoneum  allows  us  to  reach  and  oper- 
ate upon  it  by  a  lumbar  incision  frithont  openinc/  the  peritoneum,  and 
explains  why  rupture  is  not  so  serious  as  with  the  liver,  spleen,  and 


336  THE  ABDOMEN. 

intestines,  as  the  extravasation  is  usually  extraperitoneal.  Wounds 
of  the  kidney  from  behind  may  readily  occur  without  injury  to  the 
peritoneum.  Although  the  kidney  is  quite  well  protected  by  thick 
muscles  behind,  its  consistence  allows  it  to  be  not  uncommonly  rup- 
tured by  external  violence.  As  it  lies  at  the  angle  of  the  bend  when 
the  back  is  bent  far  forward,  it  may  be  caught  and  squeezed  between 
the  lower  ribs  and  the  ilium,  or  ruptured  by  a  heavy  weight  falling 
upon  the  bent  back,  while  the  kidneys  are  caught  in  the  bend. 

The  fixation  of  the  kidneys  is  due  to  the  imbedding  fat  (tunica 
adiposa),  derived  from  the  subperitoneal  connective  tissue,  and  to  the 
overlying  parietal  peritoneum,  which  is  connected  with  the  kidney  and 
its  "fatty  capsule."  The  latter,  usually  scant  at  birth,  increases  about 
puberty  and  in  adult  life  and  is  found  most  abundantly  along  the 
borders  and  posteriorly.  When  this  fatty  tissue  is  absorbed,  owing 
to  emaciation  from  any  cause,  the  kidney  loses  its  support  and  may 
become  movable  from  slight  causes  ;  tight  lacing,  enlarged  liver,  ac- 
cumulations above  the  diaphragm,  external  violence,  traction  of  the 
ureter,  colon  or  duodenum,  and  increased  weight  of  the  kidney.  As 
the  kidney  is  also  supported  by  intra-abdominal  pressure,  the  exciting 
cause  of  a  movable  kidney  may  be  a  relaxation  of  the  abdominal  walls, 
as  the  result  of  labor,  removal  of  tumors,  etc.  Hence  we  can  under- 
stand why  movable  kidney  is  so  much  more  common  in  women  than  in 
men.  It  is  also  more  common  on  the  right  side  (90  to  95  per  cent,  of 
cases)  than  on  the  left,  a  fact  probably  due  largely  to  the  liver,  pressed 
down  upon  it  by  tight  lacing,  hammering  on  the  kidney  with  each 
inspiration.  The  excursion  of  a  movable  kidney  is  limited  by  the 
length  of  its  vessels.  These  may  become  lengthened  and  usually 
allow  it  to  slip  down  far  enough  behind  the  peritoneum  to  be  palpable 
below  the  costal  margin  in  front.  In  floating  kidney  the  mesonephron, 
or  peritoneal  pedicle  containing  the  unduly  long  blood  vessels,  allows 
a  wider  excursion,  to  the  anterior  abdominal  wall,  the  iliac  fossa  or 
even  to  the  pelvic  cavity.  The  longer  the  pedicle  the  greater  the 
danger  of  torsion  of  the  pedicle  and  atrophy  or  gangrene  of  the  kidney. 
Movable  kidneys,  when  the  symptoms  demand  it,  may  be  fixed  by 
suture  to  the  edge  of  a  lumbar  incision. 

It  is  through  ih\?,  fatty  capsule,  which,  if  excessive,  protrudes  hernia- 
like into  the  incision,  that  we  work  our  way  by  blunt  dissection  in 
order  to  expose  the  kidney  through  the  lumbar  incision.  The  loose- 
ness of  this  tissue  permits  the  ready  enucleation  of  the  kidney,  except 
in  cases  where  it  becomes  adherent  to  the  kidney  as  the  result  of 
inflammation.  If  scanty,  the  fatty  capsule  often  appears  as  a  fascial 
membrane,  which  may  be  mistaken  for  peritoneum  or  transversalis 
fascia.  Again  it  is  in  this  tissue  that  perinephritic  abscesses  develop, 
from  disease  of  the  kidney  or  neighboring  parts  or  from  injury.  The 
spread  of  such  abscesses  we  can  understand  from  the  looseness  of  this 
tissue  and  its  continuity  with  the  subperitoneal  connective  tissue.  As 
such  abscesses  are  in  contact  with  the  diaphragm  above,  they  are  not 
unlikely  to  perforate  this  and  break  into  the  pleura.     Curiously  enough 


THE   VESSELS  OF  THE  KIDNEY.  337 

they  rarely  perforate  the  peritoneum.  For  further  aecounte  of  their 
course  see  posterior  relations  of  the  kidney  (p.  335)  and  abdominal 
walls,  lumbar  reg:ion  fp,  2H1), 

Misplacements  and  varieties  of  the  kidneys.  One,  more  often  the 
left,  less  often  l)oth  kidneys,  may  be  congenitally  misplaced.  This  mis- 
placement is  downward  as  a  rule,  so  that  the  organ  lies  in  the  iliac 
fossa,  on  the  pelvic  brim  or  even  in  the  pelvis.  One  kidney  is  some- 
times much  miallcr  than  the  other,  or  both  may  be  fused  together  as  a 
single  fused  mass  (1  in  8,000  cases),  with  one  or  two  pelves  and  ureters, 
or  more  often  as  a  horseshoe  hidney  (1  in  1,600  cases)  joined  at  their 
lower  ends  across  the  median  line  by  kidney  or  connective  tissue. 
When  joined  by  connective  tissue  this  is  no  bar  to  operation,  even  to 
removal  of  half  of  the  kidney.  Rarely  there  may  be  either  one  or 
three  kidneys. 

The  hilum  of  the  kidney  looks  forward,  more  or  less  inwards  and 
slightly  downwards.  Its  posterior  lip  is  thick  and  nearer  to  the 
median  line.  Of  the  principal  structures  which  enter  or  emerge  from 
the  sinus  at  this  slit-like  aperture,  the  vein  is  in  front,  the  artery 
behind  it  and  the  pelvis  of  the  ureter  the  most  posterior  and  inferior. 
Hence  the  pelvis  is  most  accessible  to  exposure //-om  behind. 

The  vessels  form  the  important  element  of  the  pedicle  in  nephrec- 
tomy and  are  to  be  ligated  together  or  separately  and  apart  from  the 
ureter  if  possible.  In  this  connection  it  is  well  to  remember  that  the 
left  artery  and  right  vein  are  shorter  than  their  fellows  and  the  short- 
ness of  the  right  renal  vein  sometimes  embarrasses  the  operator  in  a 
nephrectomy  or  other  operation  on  the  right  kidney.  The  renal 
arteries,  about  the  size  of  the  brachial,  divide  into  about  four  large 
branches  before  entering  the  hilum,  and  in  over  forty  per  cent,  of 
cases  they  present  irregularities  in  number,  place  of  entry,  etc.  Fre- 
quently one  or  more  additional  arteries  are  given  off  from  the  aorta,  or 
its  neighboring  branches,  and  pass  to  the  hilum,  the  anterior  surface 
or  either  end  of  the  kidney,  most  often  to  the  lower  end  (inferior 
renal  artery). 

The  veins  are  less  often,  but  not  frequently,  irregular.  They  may 
accompany  the  additional  arteries  at  either  end  of  the  kidney,  or  a 
branch  may  be  found  entering  the  hilum,  with  a  branch  of  the  artery, 
behind  the  pelvis.  There  would  i)e  danger  of  wounding  the  latter 
vessels  in  opening  the  pelvis  from  behind,  for  exploration  or  the 
extraction  of  a  calculus.  The  frequency  of  the  above  irregularities  in 
the  vessels  should  be  borne  in  mind  in  a  nephrectomy,  for  several 
cases  are  recorded  where  supernumerary  renal  vessels,  not  entering  at 
the  hilum,  have  given  rise  to  serious,  if  not  fatal,  hemorrhage. 

Owing  to  the  deep  position  of  the  kidneys,  they  and  their  vesxcls  are 
liable  to  be  pressed  upon  in  the  supine  position  by  the  viscera  as  well 
as  by  tumors  or  the  gravid  uterus.  Hence  their  secretory  functions 
are  probably  influenced  by  changes  in  posture,  so  that  the  latter  might 
be  utilized  in  therapeutics.  CoitgcHtion  of  the  renal  vessels  mav  be 
due  to  other  causes  than  direct  pressure,  /.  e.,  ijiipedetl  circulation 
22 


338  THE  ABDOMEN. 

through  the  lungs  or  heart,  inflammation,  etc.  Long-continued  con- 
gestion begets  increase  of  the  interstitial  fibrous  tissue,  the  contraction 
of  which  later  on  produces  cirrhotic  or  atrophied  kidney,  just  as  similar 
conditions  in  the  liver  produce  cirrhosis  of  the  liver.  Owing  to  the 
anastomosis  between  the  small  vessels  of  the  surface  of  the  kidney  and 
the  branches  of  the  lumbar  vessels,  blood  letting,  cupping,  or  counter- 
irritation  in  the  loins  may  relieve  congestion  of  the  kidney.  The 
lymphatics  (both  superficial  and  deep)  accompany  the  blood  vessels  and 
enter  the  lumbar  nodes. 

The  nerves  of  the  kidney  come  from  the  renal  plexus  which  is  de- 
rived from  the  solar  and  aortic  plexuses  and  the  lesser  splanchnic 
nerves.  The  communication  of  the  renal  and  the  spermatic  plexuses 
accounts  for  the  radiation  of  the  pain  of  a  renal  colic  to  the  testicle, 
etc.  The  nausea  and  vomiting,  and  other  symptoms  of  intestinal  colic, 
or  the  rectal  and  vesical  tenesmus,  sometimes  present  in  a  renal  colic, 
are  accounted  for  by  the  relation  of  the  nerves  of  the  kidney  with  the 
ganglia  supplying  the  intestines  and  bladder.  On  account  of  the  asso- 
ciation between  the  renal  plexus  and  the  upper  lumbar  nerves  pain 
may  radiate  along  the  latter  in  renal  colic ;  and,  on  the  other  hand, 
caries  of  the  upper  lumbar  vertebrae  may  be  mistaken  for  renal  cal- 
culus, on  account  of  the  location  of  the  pain. 

The  kidney  is  surrounded  by  a  thin  but  strong  fibrous  capsule.  In 
the  healthy  condition  this  capsule  can  be  peeled  off'  from  the  kidney, 
leaving  its  surface  smooth,  for  the  two  are  only  connected  by  a  delicate 
reticulum  of  fibrous  tissue  and  minute  vessels.  In  a  cirrhotic  kidney, 
and  some  other  lesions  of  the  kidney,  this  reticulum  is  thickened  so 
that  it  is  difficult  to  peel  off  the  capsule,  and  the  renal  surface  is  left 
very  rough  when  it  is  so  removed.  Hence  these  facts  are  made  use  of 
in  autopsies  as  indicating  a  healthy  or  diseased  kidney.  In  some 
cases  of  nephrectomy,  when  it  is  difficult  to  shell  out  the  kidney  from 
its  fatty  capsule,  owing  to  previous  inflammation,  it  may  be  easier 
to  remove  it  from  within  its  fibrous  capsule. 

Operations  on  the  kidney.  The  kidney  is  incised  (nephrotomy) 
along  its  outer  border  for  exploration,  evacuation  of  pus,  or  removal  of 
a  calculus  (nephrolithotomy).  The  entire  organ  may  be  removed 
(nephrectomy)  or  it  may  be  secured  in  its  normal  position  by  suturing 
(nephorrhaphy)  when  movable. 

The  kidney  is  cvposed  for  these  purposes  by  a  vertical  or,  preferably, 
an  obliquely  transverse  lumbar  incision  in  the  iliocostal  space  between 
the  lower  ribs  and  the  iliac  crest.  To  gain  additional  room  the  in- 
cision may  be  prolonged  forward  as  far  as  the  rectus  muscle  or  en- 
larged by  making  a  flap.  In  nephrectomy  for  a  very  large  tumor, 
some  prefer  the  transperitoneal  method,  incising  as  a  rule  in  the  cor- 
responding semilunar  line.  In  the  latter  operation  the  kidney  should 
be  reached  from  the  outer  side  of  the  colon  to  avoid  the  colic  vessels. 
For  the  details  of  the  lumbar  incision  see  lumbar  region,  posterior 
abdominal  wall,  page  282. 


THE   URETERS.  339 

The  Ureters. 

The  ureters  are  about  12  inches  long  in  the  male  and  of  the  average 
widtJi  of  a  goose  quill  (one  fifth  of  an  inch),  but  show  here  and  there 
spindle-shaped  onlargoments.  They  begin  ahove  in  a  funnel-shaped 
enlargement,  the  pelvis,  which,  passing  out  at  the  back  of  the  iiilum, 
where  it  may  ije  reached  and  opened,  narrows  as  it  descends  until  it 
attains  the  cylindrical  character  of  the  ureter  opposite  the  lower  end 
of  the  kidney.  A  slight  constriction  is  said  to  occur  about  two  inches 
below  the  kidney  (Bruce  Clark). 

The  lumen  is  narrowest  at  its  lower  opening  and  in  its  passage 
through  the  bladder  wall,  hence  calculi  are  likely  to  be  arrested  here, 
where  they  can  be  readily  felt  through  the  vagina  in  the  female.  In 
cases  of  gradual  dilatation,  the  ureters  are  capalile  of  great  fl is fen.fi on, 
to  the  size  of  the  tliumb  or  even  that  of  the  small  intestine.  This  is 
not  due  to  a  backward  flow  from  the  bladder,  but  to  an  obstruction  in 
the  lower  urinary  passages,  causing  distension  and  perhaps  frequent 
contraction  of  the  bladder,  thus  preventing  the  emptying  of  the  ureter, 
for  the  ureters  cannot  be  emptied  when  the  walls  of  the  bladder  con- 
tract or  its  cavity  is  too  distended.  The  oblique  passage  of  the  ureter 
through  the  bladder  walls  downwards  and  inwards  for  |  to  |  inch  ads 
as  a  valve,  preventing  reflux  into  the  ureter,  so  that  the  fuller  the 
bladder  the  more  tightly  is  the  ureter  closed. 

Course. — The  ureters  lie  about  three  inches  apart  at  their  com- 
mencement and,  converging  as  they  descend  in  the  umbilical  (not  the 
lumbar)  region,  they  are  about  two  inches  apart  as  they  cross  the  pelvic 
brim,  near  the  sacroiliac  joint,  to  enter  the  pelvis.  They  then  follow 
the  curve  of  the  posterior  pelvic  wall  about  parallel  with  the  sides  of 
the  sacrum.  In  the  male  they  lie  in  the  parietal  attachment  of  the 
posterior  false  ligament  of  the  bladder,  in  which  they  run  forward  and 
inward  to  reach  the  bladder  \}f  inches  apart  and  1^  inches  behind  the 
prostate.  In  the  female  they  lie  in  the  base  or  root  of  the  broad  liga- 
ment three  fifths  of  an  inch  external  to  the  cervix  uteri.  Here  they 
are  crossed  in  front  by  the  uterine  arteries  and  pass  through  the  uterine 
plexus  of  veins.  They  then  cross  obliquely  the  upper  one  third  of  the 
vagina,  inclining  forwards  from  the  lateral  vaginal  wall  to  the  vesico- 
vaginal interspace,  and  pierce  the  bladder  opposite  the  middle  of  the 
front  wall  of  the  vagina.  Hence  in  the  female,  a  .ntone  impacted  in  the 
lower  half  of  the  pelvic  portion  of  the  ureter  may  be  palpated  through 
the  vagina  and  an  extensive  carcinoma  of  the  cervix  or  upj)er  end  of 
the  vagina  may  involve  and  obstruct  the  ureters.  Their  course  and 
relations  in  the  female  pelvis  are  of  vital  importance  in  operations  on 
the  female  pelvic  organs,  and  many  cases  are  recorded  where  the  ureter 
has  been  injured  in  operations  on  these  organs.  As  a  result  of  these 
injuries  several  methods  have  been  successfully  employed  of  uniting 
the  divided  ends  of  the  ureters  or  reimplanting  them  into  the  bladder 
or  intestines,  when  divided  low  down. 

The  relations  of  the  ureters  are  of  importance  for  the  purpose  of 
finding  or  avoiding  them  as  occasion  requires.     They  cross  obliquely 


340  THE  ABDOMEN. 

the  psoas  muscles  and  the  genitocrural  nerves,  being  connected  loosely 
with  the  muscle  but  firmly  with  the  external  surface  of  the  perito- 
neum. From  the  latter  circumstance  they  can  be  readily  found  for,  if 
the  peritoneum  is  stripped  up  from  the  psoas,  the  ureters  remain  at- 
tached to  the  peritoneum  |^  to  1  inch  from  the  attachment  of  the  lat- 
ter to  the  vertebrae  on  the  left  side  and  a  little  more  on  the  right  side, 
where  the  ureter  is  displaced  outward  by  the  vena  cava.  Psoas 
abscess  has  been  known  to  discharge  through  the  ureter.  On  section 
between  the  second  and  third  lumbar  vertebrse  the  right  ureter  is  4 
cm.  from  the  parietal  peritoneum  external  to  the  outer  border  of  the 
kidney,  the  left  is  6  cm.  distant. 

In  their  course  in  the  abdomen  the  ureters  are  crossed  anteriorly  by 
the  spermatic  (or  ovarian)  and  colic  vessels.  The  vena  cava  is  almost 
in  contact  with  the  right  ureter  on  its  mesial  aspect,  while  the  left  is 
separated  from  the  aorta  by  one  inch  above  and  half  an  inch  below, 
opposite  the  aortic  bifurcation.  On  the  right  side  the  ureter  is  in  near 
relation  to  the  appendix,  and  when  the  latter  points  inward  and  is 
adherent  posteriorly  the  two  may  be  in  contact,  though  the  lower  ileum 
often  intervenes.  The  possibility  of  injuring  the  ureter  should  be 
remembered  in  operations  on  the  appendix.  Near  the  pelvic  brim  it 
crosses  the  common  iliac  artery  close  to  its  bifurcation,  or  the  begin- 
ning of  the  external  iliac  (more  often  on  the  right  side),  and  lies  be- 
hind the  sigmoid  loop  on  the  left  side  and  the  lower  end  of  the  ileum 
on  the  right.  These  relations  are  important  in  ligation  of  the  iliac 
arteries. 

In  the  pelvis  the  left  ureter  is  lateral  to  the  sigmoid  mesocolon.  At 
the  bladder  the  ureter  lies  below  the  obliterated  hypogastric  artery  and, 
in  the  male,  is  crossed  superiorly  and  internally  by  the  vas  deferens, 
which  thus  comes  to  lie  between  it  and  the  bladder.  The  free  end  of 
the  seminal  vesicle  overlaps  it  from  below.  The  inner  openings  in  the 
bladder  are  about  an  inch  from  one  another  and  from  the  vesical  outlet. 

Varieties  and  Malformations. — There  may  be  only  a  single  ureter 
from  a  fused  kidney,  or  two  or  even  three  ureters  may  arise  from  one 
kidney,  from  the  late  union,  or  non-union,  of  the  middle  pelves  which 
form  the  common  pelvis.  Two  malformations  may  exist  as  the  cause 
of  hydronephrosis :  (1)  a  kind  of  congenital  valve  at  the  commence- 
ment of  the  ureter  and  (2)  an  origin  of  the  ureter  above  the  lower 
end  of  the  pelvis,  so  that  the  latter  fills  before  being  emptied  and, 
when  full,  may  press  upon  and  close  the  valve-like  opening  of  the  ure- 
ter. In  the  latter  cases  the  ureter  appears  to  come  from  the  upper 
or  middle  instead  of  the  lower  of  the  two  or  three  middle  pelves  that 
make  up  the  common  pelvis. 

The  flow  of  urine  through  the  ureters  is  due  to  the  peristaltic  con- 
traction of  their  muscular  coats,  and  may  be  aided  by  gravity  in  the 
erect  position.  It  occurs  at  regular  intervals,  sometimes  every  three 
fourths  of  a  minute  or  so,  sometimes,  as  I  have  seen,  twice  in  four  or 
five  seconds  and  then,  after  an  interval  of  sixteen  to  twenty  seconds, 
twice  again  in  four  or  five  seconds. 


PLATE   X  L 


FIG.  79. 


POST     FALSE 
LIGAMENT      ~ 
OF   BLADDER 


RECTO-VESI-. 
CAL  POUCH 


SPERMATIC 
VESSELS 


. VAS    DEFERENS 
.INT.    ABDOMI- 
NAL   RING 
DEEP    EPIGAS- 
TRIC   ARTERY 


w-  -^ 


OBLITER- 
ATED   HY 
POGAS 
TRIO 
ARTERY 


Pelvic  portion  of  llie  ureters,  formaiion  of  the  spermatic 
cord,  rectovesical  pouch,  pelvic  vessels,  etc.,  in  the  male, 
seen  from  in  front  and  above,  the  bladder  being  pulled 
forward.     (Testut. ) 


THE  SUPRARENAL  BODIES  OR  ADRENALS.  341 

The  abdominal  portion  of  the  ureters  (/.  c,  above  the  pelvic  brim) 
may  be  exposed  by  an  incision  used  to  expose  the  kidney,  passing 
obliquely  from  near  the  costovertebral  angle  toward  the  anterior  su- 
perior iliac  spine  and  then  curving  toward  the  umbilicus  ;  or  by  an 
incision  like  that  for  the  common  iliac  artery,  carried  further  upward. 
The  walis  of  the  ureter  are  about  one  twenty-fifth  of  an  inch  tliich,  com- 
posed mainly  of  muscular  and  fibrous  tissue. 

The  passage  of  a  renal  calculus  through  the  ureter  is  accomplished 
in  much  the  same  way  as  that  described  in  the  passage  of  biliary  cal- 
culi and  with  a  similar  intense,  intermittent  pain,  known  as  renal 
colic.  The  ureters  have  been  ruptured  by  external  violence.  The 
resulting  extravasation  of  urine  is  large,  retroperitoneal  and  liable  to 
suppuration,  producing  a  lumbar,  iliac  or  pelvic  abscess. 

The  Suprarenal  Bodies  or  Adrenals.     (Figs.  72  and  74.) 

These  are  two  ductless  glands,  one  of  which  rests  on  the  upper  end 
and  the  adjoining  parts  of  the  anterior  surface  and  inner  border  of 
each  kidney.  They  are  separated  from  the  kidney  by  the  perinephritic 
tunica  adiposa,  so  that  changes  in  position  of  the  kidney  do  not 
affect  the  suprarenals.  They  are  larger  at  birth  than  in  the  adult, 
they  atrophy  in  advanced  life,  and  are  degenerated  in  connection 
with  Addison's  disease.  They  i-est  upon  the  diaphragm  opposite  the 
eleventh  and  twelfth  ribs,  and  perhaps  the  tenth  interspace,  or  oppo- 
site the  adjoining  portions  of  the  eleventh  and  twelfth  thoracic 
vertebrae.  An  interval  of  2  to  2^  inches  separates  them  from  one 
another. 

The  left  is  crescentic,  flattened  from  before  backward,  and  extends 
lower  down  than  the  right  along  the  inner  border  of  its  kidney,  even 
to  the  hilum.  In  front  lies  the  stomach,  separated  by  the  lesser  peri- 
toneal sac,  and  its  lower  cornu  is  crossed  by  the  pancreas  and  the 
splenic  vessels.  Externally  it  is  in  contact  with  the  upper  end  of  the 
spleen.  The  right  suprarenal  is  more  triangular,  laterally  compressed 
and  vertically  elongated,  but  reaches  no  higher  than  the  left,  owing  to 
the  lower  position  of  the  right  kidney.  It  is  related  in  front  to  both 
the  inferior  and  posterior  surfaces  of  the  right  lobe  of  the  liver  (im- 
pressio  saprarenalis) ;  internally  to  the  vena  cava,  which  slightly  over- 
laps it,  and  its  inferior  angle  is  crossed  by  the  first  bend  of  the  duo- 
denum. It  lies  beliind  the  foramen  of  AVinslow.  The  left  suprarenal 
is  covered  with  peritoneum  ai)ove,  the  right  below. 

The  nei^ve  supply  of  the  suprarenals  is  remarkably  abundant,  derived 
mainlv  from  the  solar  and  renal  })lexuses,  with  some  branches  from 
the  phrenic  and  vagus  nerves.  The  sujirarenals  are  of  little  or  no 
surgical  importance  as  yet  and  may  be  disregarded  in  operations  on 
the  kidneys,  except  that  the  blood  supply  of  the  two  is  more  or  less 
connected,  especially  on  the  left  side.  The  extract  of  these  bodies  is 
a  remarkably  strong  astringent  ami  has  also  l>een  used  thcrajKnitically 
in  Addison's  disease,  etc. 


342  THE  ABDOMEN. 

Blood  Vessels  of  the  Abdomen. 

The  following  is  in  addition  to  the  mention  made  under  the  several 
organs  and  the  parietes. 

The  abdominal  aorta  varies  in  its  distance  from  the  ventral  surface 
in  different  individuals,  but  in  general  it  approaches  nearer  tJte  surface 
as  it  nears  its  bifurcation.  Hence  the  most  favorable  point  for  compres- 
sion of  the  aorta  is  just  above  the  umbilicusj  for  it  bifurcates  just  below 
and  to  the  left  of  this  point.  But  even  here  it  cannot  be  readily  felt 
or  satisfactorily  compressed  unless  the  bowels  are  quite  empty. 

Aneurism  is  most  likely  to  occur  at  or  near  the  coeliac  axis  which 
is  a  weak  spot,  often  giving  way  in  injections  of  the  cadaver,  for  here 
several  large  branches  are  given  off  and  cause  a  sudden  deviation  in 
the  course  of  the  circulation.  Such  an  aneurism  gives  rise  to  a  pulsat- 
ing tumor  in  the  epigastric  or  umbilical  region,  but  a  tumor  of  the 
organs  in  front  of  the  aorta  (pylorus,  pancreas,  colon)  may  also  receive 
a  pulsation  (not  expansile)  from  the  aorta.  Pressure  of  the  aneurism 
on  the  diaphragm,  oesophagus,  and  stomach  may  cause  dyspnoea,  dys- 
phagia and  vomiting ;  on  the  vena  cava  oedema  of  the  legs  ;  on  the 
renal  veins,  albuminuria  ;  on  the  lumbar  nerves,  pain  in  the  back,  but- 
tocks, or  thigh  ;  on  the  sympathetic  plexuses,  indigestion,  visceral  pains, 
reflex  pains  in  the  lumbar  nerves,  etc.,  etc. 

INIany  of  the  branches  of  the  abdominal  aorta  are  of  large  size,  the 
coeliac  axis  and  superior  mesenteric  are  of  the  size  of  the  common  caro- 
tid ;  the  hepatic,  splenic,  and  renals  equal  the  brachial  in  size. 

The  number  of  minute  extraperitoneal  anastomoses  between  the 
branches  of  the  parietal  vessels  (lower  intercostal,  phrenic,  lumbar, 
iliolumbar,  epigastric,  and  circumflex  iliac)  and  branches  of  vessels 
which  supply  viscera  not  entirely  covered  by  peritoneum  (liver,  kidney, 
adrenals,  duodenum,  pancreas,  ascending  and  descending  colon)  are  of 
great  importance  in  case  of  obstruction  to  the  arterial  supply  of  the  vis- 
cera. The  corresponding  venous  anastomoses  are  of  equal  or  greater 
importance  in  case  of  obstruction  of  either  the  vena  cava  or  the  portal 
vein.  A  parumbilical  vein  may  also  directly  connect  the  portal  vein 
with  the  epigastric,  and  thus  with  the  external  iliac  veins,  and  be  of 
much  service  in  relieving  obstruction  of  the  portal  circulation,  as  in 
cirrhosis.  The  above  anastomoses  explain  the  efiect  of  surface  blood- 
letting and  counter-irritation  in  inflammation  or  congestion  of  the 
partly  extraperitoneal  viscera. 

The  co?Iiac  axis,  with  a  semilunar  ganglion  on  either  side,  arises 
opposite  the  top  of  the  first  lumbar  vertebra,  about  four  inches  above 
the  umbilicus.  The  renal  artery  arises  opposite  the  lower  end  of  the 
same  vertebra  (that  of  the  right  side  somewhat  lower),  the  inferior 
mesenteric  about  two  inches  above  the  aortic  bifurcation,  or  H  inches 
above  the  umbilicus.  The  left  renal  vein,  crossing  in  front  of  the 
aorta,  to  reach  the  vena  cav^a,  is  an  exception  to  the  rule  that  below 
the  diaphragm  the  large  veins  pass  behind  the  large  arteries,  while 
above  the  diaphragm  they  pass  in  front. 


NERVE  SUPPLY   OF  THE  ABDOMINAL    VISCERA.  343 

Lymph  Nodes  of  the  Abdomen. 

Besides  the  lymphatic  nodes  already  noticed,  in  connection  with  the 
organs,  there  is  a  central  series  of  retroperitoneal  li/mph  nodes  arranged 
in  tiro  fjroiips.  (1)  The  lumbar  nodes,  twenty  to  thirty  in  number,  lie 
on  the  sides  and  in  front  of,  or  even  between,  the  aorta  and  vena  cava. 
Great  enldrgeiaent  of  these  nodes  may  cause  (edema  from  pressure  on 
the  vena  cava.  Tiiey  receive  the  lymphatics  from  the  external  iliac 
nodes,  the  pelvis,  kidneys,  adrenals  and  the  sigmoid  flexure.  (2) 
The  coeliac  nodes,  sixteen  to  twenty  in  number,  lie  above  the  pancreas, 
near  the  celiac  axis,  and  receive  lymphatics  from  the  stomach,  spleen, 
pancreas,  part  of  tlie  liver  and  the  mesenteric  nodes. 

Nerve  Supply  of  the  Abdominal  Viscera. 

This  is  derived  from  a  series  of  plcciDi&i  formed  by  tlie  Hyrnpatlietic 
.si/stem  with  some  branches  from  the  vagus  and  phrenic  nerves.  Tiie 
two  f/reat  splanchnic  nerves,  descending  from  the  thorax,  end  in  the 
two  large  semilunar  ganglia,  one  on  either  side  of  the  cceliac  axis. 
These  are  united  together,  aud  with  many  small  surrounding  ganglia, 
by  a  network  of  fibrils  to  form  the  solar  or  coeliac  plexus,  which  also  re- 
ceives twigs  from  the  vagus  and  phrenic  nerves.  From  this  central 
plexus  branch  plexuses  are  derived  which  accompany  the  visceral 
branches  of  the  aorta,  except  the  inferior  mesenteric,  to  the  organs 
which  they  supply.  The  renal  plexus  also  receives  the  lower  splanch- 
nic nerves.  Mesial  branches  of  the  lateral  sympathetic  cords  form  the 
aortic  plexus  in  front  of  the  aorta  below  the  inferior  mesenteric  artery, 
along  which  a  branch,  the  inferior  mesenteric  pleonts,  passes  to  the 
viscera  supplied  by  the  artery. 

These  plexuses,  and  the  nerves  which  go  to  form  them,  communi- 
cate with  the  thoracic  and  lumbar  spinal  nerves  and  thus  account  for 
many  reilexes,  i.  e.,  the  reflex  pains  and  muscular  contractions  in  the 
course  of  the  spinal  nerves  in  case  of  peritonitis,  etc.  (see  p.  251). 
The  "sympathetic"  or  reflex  pain  between  the  shoulders,  or  about  the 
angles  of  the  scapulae,  in  some  diseases  of  the  stomach  and  liver,  are 
probably  due  to  a  reflex  in  the  fourth,  fifth  and  sixth  thoracic  nerves, 
which  supply  these  parts  and  communicate  with  the  great  splanchnic 
nerves  which,  through  the  solar  plexus,  go  to  supply  the  liver  and 
stomach.  Reflex  pain  in  the  tip  of  the  shoulder  has  already  been 
referred  to  (see  liver,  p.  325). 

From  the  extent  of  these  abdominal  nerve  centers,  especially  the 
solar  plexus,  we  can  understand  what  profound  ejf'ects,  collapse,  vomit- 
ing and  even  death  may  attend  an  injxi'i/  to  them,  or  tiie  viscera  most 
closely  associated  with  them.  Hence  the  danger  of  a  blow  over 
the  pit  of  the  stomach,  /.  c,  over  the  solar  plexus,  which  may  even 
cause  death  without  marks  of  external  injury,  and  always  causes  shock 
out  of  all  proportion  to  the  extent  of  the  injury.  Hence  also  an 
injury  to  those  viscera  which  are  more  remotely  eoinieeted  with  the 
nerve  centers,  such  as  the  descending  colon  which   is  supplied  by  the 


344  THE  ABDOMEN. 

inferior  mesenteric  plexus,  only  indirectly  connected  with  the  solar 
plexus,  or  even  the  ascending  colon  supplied  by  a  part  of  the  superior 
mesenteric  plexus  most  remote  from  the  centers,  is  accompanied  by 
less  serious  symptoms.  It  is  noteworthy  that  the  nearer  the  lesion  is 
to  the  stomach,  other  things  being  equal,  the  more  profound  are  the 
nervous  phenomena  produced.  Distant  pain  in  disease  of  the  ab- 
dominal viscera  is  not  necessarily  reflex  but  may  be  due  to  pressure. 
Thus  pain  in  the  knee  may  be  due  to  the  pressure  of  the  sigmoid 
flexure,  distended  with  faeces  or  affected  with  cancer,  upon  the  obtu- 
rator nerve. 


CHAPTER  y. 

PELVIS   AND    PERINEUM. 

THE    PELVIS. 

We  have  already  studied,  in  a  preceding  section,  the  upper  part  or 
false  pelvis  which  supports  some  organs  and  attaches  many  muscles  of 
the  al)d()men.  It  remains  to  study  the  true  pelvis  and  its  viscera. 
The  external  or  superficial  boundaries  of  this  region  are  not  well  marked, 
for  it  is  covered  by  the  parts  of  other  regions,  i.  e.,  the  buttocks  be- 
hind, tiio  hips  at  the  side  and  the  perineum  below.  Hence  there  are 
but  few  bony  or  other  landmarks.  Some  of  these  we  have  considered 
under  the  landmarks  of  the  abdomen  (see  pp.  237-8). 

From  the  pubic  spine,  mesially,  to  the  symphysis  we  can  make  out 
the  front  of  the  pelvic  brim,  formed  by  the  pubic  crests,  and  below  this 
the  bodies  of  the  two  pubic  bones,  separated  by  the  symphysis  pubis. 
This  part  is  covered  in  the  female  by  a  thick  pad  of  subcutaneous  fat, 
the  mons  veneris,  which  somewhat  obscures  the  bony  outlines.  The 
mons  veneris  is  separated  from  the  abdomen  above  by  a  transverse 
furrow  which  meets  the  inguinal  furrows  about  their  center. 

Still  further  down  in  the  median  line  we  can  feel  the  subpubic  angle 
on  deep  pressure  behind  the  scrotum  in  the  male,  in  the  vestibule  in 
the  female.  Leading  from  this  angle  to  the  ischial  tuberosities  we  can 
trace  the  combined  rami  of  the  pubis  and  ischium  on  each  side,  which 
bound  the  perineum  laterally  and  lie  nearly  in  the  genito-cmral furrows. 
The  latter  are  the  furrows  between  the  inner  aspect  of  the  thighs  and 
the  perineum  and  are  continuous  behind  with  the  (/lufni/  /oW.s.  It  is 
near  the  inner  end  of  the  latter  that  the  ischial  tuberosities  can  be 
readily  felt.  In  the  sitting  posture  these  tul)er()sities  are  only  sepa- 
rated from  the  skin  by  the  subcutaneous  fat  and  a  bursa.  This  bursa 
is  liable  to  ivJJammaiion  in  those  who  sit  a  great  deal,  like  coachmen, 
weavers,  etc.  Hence  the  construction  of  many  so-called  anatomical 
bicycle-saddles,  for  it  is  on  the  tuberosities  that  we  rest  in  sitting.  In 
the  standing  posture  the  tui)erosities  are  overlaj)|ied  by  the  lower 
borders  of  the  gluteus  maximus  muscles.  The  ischial  tuberosities  form 
one  end  of  Nelaion's  line  (see  p.  427),  and  the  line  connecting  them 
divides  the  perineum  proper  in  fn>nt  from  the  ischiorectal  fossa 
i)ehind. 

In  the  iiu'didii  line  heliind  we  can  feel  the  sjtinons  jtrorrxs  of  the  fifth 
lumbar  vertebra,  often  indicated  by  a  little  furrow,  and  below  this 
those  of  the  sacral  vertebne,  of  which  the  thiiti  is  the  most  prominent. 

345 


346  PELVIS  AND  PERINEUM. 

Following  down  in  the  median  line,  in  the  deep  fold  between  the  but- 
tocks, we  can  feel  the  tip  of  the  coccyx,  behind  which  (especially  in 
women)  there  is  often  a  more  or  less  marked  dimple  or  depression  of 
the  skin  {Joveola).  Through  the  vagina  or  rectum  can  he  felt  posteriorly 
the  front  of  the  coccyx  and  sacrum,  laterally  the  spines,  the  inner 
aspect  of  the  tuberosities  and  the  bodies  of  the  ischia  and  the  great 
sacrosciatic  foramina,  and  anteriorly  the  back  of  the  pubic  bones 
and  symphysis  and  the  obturator  foramina.  With  a  long  finger  or  half 
hand,  when  the  patient  is  anaesthetized,  the  sacral  promontory  can  be 
felt  above  and  behind,  but  if  this  can  be  felt  in  an  ordinary  examina- 
tion by  a  finger  of  ordinary  length  the  pelvis  is  considered  abnormal. 
The  promontory  can  also  be  felt  on  deep  pressure  through  a  thin  lax 
abdomen,  about  on  a  level  with  the  anterior  superior  iliac  spines. 

The  Bony  Pelvis. — Although  in  the  bony  state  the  outlet  or  brim 
of  the  pelvis  is  heart-shaped  with  the  base  behind,  in  the  natural  state 
the  psoas  and  other  muscles  make  it  triangular  with  the  base  in  front. 
The  outlet  of  the  pelvis  is  composed  of  three  bony  points  separated  by 
three  notches.  The  two  symmetrically  placed  posterior  notches  (sacro- 
sciatic) are  bridged  across  by  the  strong  sacrosciatic  ligaments  which 
thus  bound  the  pelvic  outlet  and  make  it  lozenge-shaped.  The  tuber- 
osities of  the  ischium  may  be  quite  close  together  in  the  male.  I 
have  seen  this  condition  so  marked  as  to  embarrass  one  in  lateral  lith- 
otomy. In  the  natural  position  of  the  pelvis  the  tuberosity  lies  behind 
and  below  the  acetabulum,  and  only  a  trifle  further  behind  it  than  the 
anterior  superior  iliac  spine  is  in  front  of  it.  Also  the  ischial  suine 
lies  I  of  an  inch  above  the  upper  border  of  the  symphysis. 

The  coccyx  may  be  fractured  or  dislocated  as  a  result  of  falls  or 
blows  or  during  parturition,  especially  in  those  women  in  whom  the 
coccyx  is  much  incurved  as  the  result  of  sedentary  habits  or  horseback 
riding.  The  displacement  of  the  fracture  or  dislocation  may  be  readily 
made  out  by  rectal  examination,  or  by  a  finger  in  the  rectum  and  the 
thumb  on  the  surface.  The  joint  between  the  coccyx  and  the  sacrum 
may  also  be  diseased.  All  these  conditions  are  very  painful,  owing  to 
the  frequent  movement  at  the  seat  of  injury,  due  to  the  muscles  attached 
to  the  coccyx  (gluteus  maximus,  coccygeus,  levator  and  sphincter  ani). 
The  injured  bone  may  project  into  the  rectum  and  be  moved  in  de- 
fecation mechanically  as  well  as  by  the  sphincter  and  levator  ani 
muscles.  The  sacro-coccygeal  joint  and  the  parts  about  the  bone  are 
supplied  by  the  posterior  divisions  of  the  coccygeal  and  the  second  to 
the  fifth  sacral  nerves  and  the  anterior  divisions  of  the  fifth  sacral  and 
the  coccygeal  nerves,  which  may  be  the  seat  of  a  painful  neuralgia  (coc- 
cydijnia).  Removal  of  the  coccyx  may  be  called  for  on  account  of 
injury,  joint  disease  or  neuralgia. 

Sacro-coccygeal  Tumors. — These  are  usually  congenital,  and  I  have 
seen  them  attain  such  a  size  that  the  possessor,  a  man,  wore  skirts  to 
conceal  the  enormous  mass.  Some,  springing  from  between  the  coccyx 
and  the  rectum,  contain  epithelial  cysts  and  even  fragments  of  tissue, 
i.  e.,  cartilages,  bone,  muscle,  nerve,  skin,  raucous  membrane.     They 


SA  CR 0-ILIA  C  JOINT.  34  7 

are  supposed  to  arise  from  the  embryonic  neurenieric  passage,  or  post- 
anal gut,  though  they  were  formerly  thought  to  originate  from  Luschka's 
gland.  These  tumors  are  t/ti/roid-derinoid.i.  DennouU  also  occur  over 
the  back  of  the  sacrum  and  coccyx,  where  they  may  be  confounded 
with  si)ina  bifida.  Some  take  such  a  shape  as  to  form  "  human  tails." 
Aftdc/ial  hniiian  fretuses  are  often  joined  together  at  this  j)art  of  the 
column,  and  here  too  third  limbs  (tripodesia)  and  parasitic  foetuses  are 
found  attached. 

Sacro-iliac  Joint. — Normally  there  is  no  movement  in  this  joint 
except,  as  Farabeuf  has  shown,  a  s/if/Jif  rotation  on  a  transverse  axis. 
Thus  when  the  thighs  are  flexed  onto  the  abdomen  the  conjugate 
diameter  is  shortened  by  the  rotation  upward  of  the  innominate  bones, 
the  symphysis  approaching  the  ])romontory.  The  reverse  occurs  on 
hyperextension  of  the  thighs,  which  may  therefore  be  made  use  of  in 
obstetrics  to  slightly  increase  the  conjugate  diameter  of  the  brim.  In 
general  the  joint  screes  merely  to  break  sJiochs,  but  some  movement  is 
said  to  occur  when  the  ligaments  are  softened  by  disease. 

The  joint  may  become  diseased  as  the  result  of  injury,  by  an  exten- 
sion from  spinal  caries,  etc.,  or  spontaneously.  In  the  two  latter 
instances  it  is  usually  tubercular.  In  disease  of  this  joint  much  pnin 
is  felt  in  standing  or  sitting,  as  in  these  positions  the  weight  of  the 
body  is  transmitted  through  it.  This  pain,  besides  being  local,  may 
also  be  of  a  peripheral  reflex  character  over  the  sacral  region  (upper 
sacral  nerves),  in  the  buttocks  (gluteal  nerve),  or  even  at  times  in  the 
thigh  and  calf  (lumbosacral  cord).  The  above-named  nerves  supply 
the  joint,  which  sometimes  gets  a  small  twig  from  the  obturator  nerve 
which,  with  the  lumbosacral  cord,  passes  over  the  front  of  the  joint. 
The  obturator  nerve  accounts  for  referred  pain  in  the  knee  or  hip  joints. 

If  abscess  forms  it  usually  comes  foricard  into  the  pelvis,  as  the 
anterior  ligaments  are  much  the  thinner  and  weaker.  Such  an  abscess 
may  enter  the  iliopsoas  sheath,  perforate  the  rectum,  or  follow  the 
lumbosacral  cord  and  sciatic  nerve  to  the  back  of  the  thigh,  or  the 
obturator  nerve  to  the  inner  aspect  of  the  thigh.  More  rarely  the 
abscess  may  pa.ss  backward  and  point  behind  the  joint.  In  examin- 
ing the  joint  from  behind,  it  is  useful  to  know  that  the  po.sterior 
superior  iliac  spine  corresjxinds  to  its  center. 

In  spite  of  the  comparative  weakness  of  the  anterior  sacro-iliac  liga- 
ments, above  mentioned,  dislocation  never  occurs  except  in  fracture  of 
the  pelvis,  or  the  rare  luxation  of  the  sacrum  anteriorly.  This  fact  is 
due  to  the  very  strong  po.sterior  sacro-iliac  ligaments,  which  sling  the 
sacrum  from  the  ilium,  and  not  to  the  wedge  shape  of  the  sacrum  for. 
in  the  natural  position  of  the  pelvis,  the  base  of  the  wedge  looks  down- 
ward and  forward,  /.  r.,  in  th(>  direction  in  which  the  weight  of  the 
bodv  would  naturally  tend  to  disj)lace  it.  The  wedge  shape  would 
prevent  its  l)eing  dislocated  l)ack\\ard,  l)ut  there  is  no  tendency  to  this 
displacement.  At  the  .sime  time,  owing  to  the  irregularities  of  the 
bony  surfaces  and  the  slight  projecting  lips  of  the  ilia  in  front  and 
below,  the  sacrum  is  more  or  le.ss  wedged  in  between  the  ilia  like  the 


348  PELVIS  AND  PERINEUM. 

keystone  of  an  arch,  to  the  pillars  of  which,  the  ilia,  it  transmits  the 
weight. 

The  innominate  bones  can  be  separated  at  the  symphysis,  in  sym- 
physiotomy, but  a  very  little  distance  without  first  straining  the  front 
of  the  sacro-iliac  joint,  then  tearing  the  anterior  ligaments  and  the  carti- 
lages connecting  the  bony  surfaces.  In  addition  to  the  tearing  of  the 
anterior  ligaments  the  periosteum  is  usually  strij)ped  up  for  some  dis- 
tance on  the  ilium  in  front  of  the  joint.  As  the  axis  of  this  separation 
or  opening  of  the  joint  is  at  the  back  of  the  joint  and  passes  obliquely 
downward  and  inward,  the  strong  posterior  sacro-iliac  ligaments  avoid 
injury  and  the  pubic  bones  on  being  separated  pass  downward  as  well 
as  outward. 

The  symphysis  pubis  is  nearly  2  inches  in  height,  and  its  thickness 
may  reach  nearly  1  inch.  In  symphysiotomy,  proposed  by  Sigault  in 
1708  as  a  substitute  for  Csesarean  section  to  enlarge  the  pelvic  di- 
mensions in  labor  in  cases  of  contracted  pelvis,  a  separation  at  the 
symphysis  of  2J  inches  increases  the  conjugate  diameter  by  only  half 
an  inch.  But,  as  the  convexity  of  the  child's  head  may  project  into 
the  interval  between  the  separated  pubic  bones,  another  half  inch  or  so 
may  be  gained  for  the  passage  of  the  head.  In  addition  to  the  laceration 
of  the  sacro-iliac  joints  resulting  from  the  separation  at  the  symphysis, 
to  which  we  have  just  referred,  the  attachments  of  the  pelvic  viscera 
may  be  damaged.  A  slight  separation  of  the  pubic  bones  due  to  swell- 
ing of  the  fibrocartilage  has  been  shown  to  occur  toward  the  end  of 
gestation,  but  during  parturition  the  decussating  tendinous  fibers  of 
the  abdominal  muscles,  which  cross  in  front  of  the  joint,  would  tend  to 
brace  the  bones  more  tightly  together. 

Separation  at  the  si/mphi/sis  without  fracture  of  the  bones  has  occurred 
from  severe  external  violence,  and  Malgaigne  has  reported  three  cases 
where  the  violence  was  muscular  merely,  due  to  excessive  action  of  the 
adductors  of  both  sides. 

The  Mechanism  of  the  Pelvis. — The  weight  of  the  body  is  trans- 
mitted from  the  sacrum  through  the  pelvis  along  tiro  arches,  one  for  the 
standing,  the  other  for  the  sitting  posture.  The  arch  for  tJie  standing 
posture  consists  of  the  sacrum,  the  sacro-iliac  joints,  the  acetabula,  and 
the  thick  ridges  of  bone  along  the  ilio-pectineal  line  between  the  two 
latter  points.  For  the  sitting  posture  fJie  arch  is  much  the  same,  ex- 
cept that  the  ischial  tuberosities  are  substituted  for  the  acetabula. 
These  tino  arches  have  been  called  the  femorosacral  and  the  ischiosucral 
respectively.  The  bone  in  the  line  of  these  two  arches  is  much  thicker 
than  elsewhere  in  the  pelvis.  The  sacrum  occupies  the  position  of  the 
kf^ystone  for  both  arches  (see  above,  p.  347). 

To  strengthen  each  arch  its  ends  are  joined  by  a  counter  arch,  which 
completes  a  ring  and  serves  as  a  tie  to  keep  the  sides  of  the  arch  from 
separating  or  colla|)sing.  The  counter  arch  or  tie  of  the  femorosacral 
arch  is  formed  by  the  bodies  and  horizontal  rami  of  the  pubcs,  that  of 
the  ischiofemoral  arch  by  the  combined  rami  of  the  pubes  and  ischia. 
Thus  the  ties  of  both  arches  meet  at  the  symphysis,  to  which  is  conveyed 


FRACTURES  OF  THE  PELVIS.  349 

a  portion  of  the  weight  or  strain.  Hence  the  strain  felt  at  the  sym- 
physis when  increased  weight  is  to  be  home,  as  in  pregnancv,  abdomi- 
nal tumors,  etc.,  and  hence  the  inability  to  stand  or  sit  when  tlie 
symphysis  is  diseased  or  weakened  by  injury  or  an  unhealed  sym- 
physiotomy. 

Pelvic  deformities  are  also  explained,  according  to  the  mechanism 
of  the  pelvis,  by  the  weight  acting  on  bones  that  have  not  become 
properly  ossitied  in  parts,  owing  to  rickets,  or  on  bones  uniformly 
softened  by  the  much  rarer  condition,  osteomalacia.  When  the 
rickety  child  walks  but  little  and  sits  most  of  the  time,  as  thev  fre- 
quently do,  the  weight  of  the  body  thrusts  the  sacral  promontory  for- 
ward and  downward,  thus  diminishing  the  conjugate  diameter  of  the 
brim.  The  counter  pressure  comes  from  the  ischial  tuberosities  and  is 
most  felt  in  the  counter  arch,  which  is  narrowed  and  pushed  forward 
at  the  symphysis,  while  the  tuberosities  may  approach  one  another  and 
narrow  the  transverse  diameter  of  the  outlet.  If  the  rickety  child  is 
more  on  its  feet,  lateral  counter  pressure  is  exercised  at  the  acetabula, 
and  is  felt  mostly  at  the  weakest  part  of  the  pelvis,  /.  e.,  the  counter 
arch.  Thus  while  the  acetabula  approach  one  another  more  or  less, 
the  most  marked  change  is  a  Ijeak-like  projection  of  the  symphvsis, 
the  pubic  rami  sometimes  running  parallel  with  one  another  and  close 
together,  showing  a  collapse  of  the  counter  arch. 

In  the  softer  condition  due  to  oMeonuilacia,  which  occurs  only  in 
adult  life,  these  changes  due  to  lateral  pressure  are  most  marked. 

Fractures  of  the  Pelvis. — Though  the  sacro-iliac  joints  and  the 
sympliysis  might  be  thought  to  be  weak  points  of  the  pelvis,  their 
connecting  ligaments  are  so  strong  that  they  rarely  give  way  pri- 
marily; the  bones  yield  first.  As  has  been  just  said  the  counter  arch 
is  the  ivea/ceM  point,  and  it  is  here  that  fracture  commoufi/  occurs 
from  the  most  varied  forms  of  violence.  Fractures  of  the  pelvic 
arch  usually  occur  as  the  result  of  violent  pressure  on  the  surface 
or  of  falls  from  a  height.  Thus,  if  the  force  be  applied  in  the 
antero-posterior  direction,  the  weak  counter  arch  yields  to  direct  or 
indirect  violence  on  one  or,  possibly,  both  sides  of  the  symphysis 
through  the  pubes  or  the  rami.  The  force  continuing  tends  to  sepa- 
rate the  two  hip  bones  and  to  cause  a  diastasis  and  finally  a  dislo- 
cation of  the  sacro-iliac  joints,  as  in  symphysiotomy.  Again,  if  the 
force  be  applied  transversely,  the  pelvis  tends  to  become  flattened  lat- 
erally, but  the  weaker  counter  arch  is  more  bent  and  eventually  gives 
way  and  is  fractured  by  indirect  violence.  Should  the  force  continue, 
the  two  hip  bones  are  pressed  toward  one  another  and  the  strain  on 
the  sacro-iliac  joint  falls  upon  its  posterior  part.  Here  the  ligaments 
are  so  strong  that,  instead  of  their  rupture,  portions  of  bone  to  which 
they  are  attached,  especially  the  sacrum,  are  usually  torn  away.  In 
falls  on  the  feet  or  ischial  tuberosities,  it  is  again  the  weaker  or  counter 
arch  which  is  usually  fractured.  In  falls  from  a  height  or  other  severe 
injuries,  the  head  of  the  femur  may  be  driven  through  the  aeetai)ulum, 
but  this  is  rare. 


350 


PELVIS  AND  PERINEUM. 


A  separation  of  the  hip  bone  into  its  three  constitutent  parts  cannot 
occur  after  about  the  eighteenth  year,  at  which  time  the  three  parts  are 
firmly  united  by  the  ossification  of  the  Y-shaped  cartilage.  Before 
this  occurs  abscess  within  the  capsule  of  the  hip  joint  may  make  its 
way  into  the  pelvis  through  the  cartilage,  but  this  is  not  as  common 
an  occurrence  as  one  would  expect.  Localized  direct  violence  of  suffi- 
cient force  may  fracture  any  part  of  the  pelvis. 

Apart  from  the  fact  that  the  violence  producing  fractures  of  the  pel- 
vis is  usually  severe  and  entails  shock  and  often  other  remote  injuries, 
such  fractures  are  serious  on  account  of  and  in  proportion  to  the  injury 
to  the  pelvic  viscera  from  sharp  fragments  or  loose  pieces  of  bone,  or 
from  crushing  or  tearing.  Thus  the  bladder  and  urethra,  and  in  the 
female  the  vagina,  are  especially  liable  to  be  torn  by  sharp  fragments, 
and  the  urethra  may  be  ruptured  or  compressed,  owing  to  its  close 
relation  to  the  subpubic  arch.  A  vesical  calculus  has  been  reported 
having  for  its  nucleus  a  piece  of  bone  driven  into  the  bladder  in  a 
fracture  of  the  pelvis.  It  is  in  the  double  fractures  of  the  pelvic  arch 
that  the  viscera  are  most  often  wounded.  In  these  double  fractures 
the  two  lines  of  fracture  are  most  often  on  one  side  of  the  symphysis, 
rarely  on  both  ;  or  in  place  of  the  second  fracture  we  may  have  a 
diastasis  of  the  symphysis,  which  usually  occurs,  if  at  all,  in  connection 
with  fractures  of  the  pelvic  arch.  The  rectum  too  has  been  torn  or 
compressed  in  fractures  of  the  sacrum  or  coccyx.  Information  may 
often  be  gained  for  the  diagnosis  of  fracture  of  the  pelvis  by  rectal  or 
vaginal  examination,  and  blood  in  the  urine  in  such  cases  indicates  an 
injury  to  the  bladder  or  urethra.  The  capsule  of  the  hip  joint  is 
almost  always  external  to  the  line  of  fracture  of  the  pelvic  arch  and 
thus  escapes  injury. 

Fig.  80. 


FIFTH     LUMBAR 
VERTEBRA 


ANTERIOR   SUPERIOR 
ILIAC    SPINE 
ANTERIOR       INFERIOR 
ILIAC    SPI  NE 
POUPART'S. 
LIGAMENT 

PUBIC   SPINE 


OBTURATOR 
MEMBRAN  Z 


POST. -SUP.    ILIAC 

SPINE 
POST. -INF.    ILIAC 

SPINE 
GREAT    SACRO- 

SCIATIC    FORAMEN 
GREAT    SACRO-SCIATIC 

LIGAMENT 
SMALL    SACRO-SCIATIC 

LIGAMENT 
^SMALL    SACRO-SCIATIC 

FORAMEN 


ISCH     TUBEROSITY 


Female  pelvis  viewed  from  the  left  side,  showing  the  position  of  its  parts  in  the  erect  posture. 

(JOES.SEL.  ) 


AXES  AND  DIAMETERS  OF  THE  PELVIS.  351 

In  the  erect  position  the  phine  of  the  hrim  or  outlet  of  a  normal 
pelvis  makes  an  angle  of  50°  to  00°  with  the  horizon,  which  is  due  to 
the  sacrovertebral  angle  and  the  obliquity  of  the  articulation  of  the 
hip  bones  with  the  sacrum.  This  antero-posterior  tilting,  which  we 
call  the  obliquity  of  tlic  jjc/cis,  varies  in  different  cases  and  averages 
greater  in  the  female  than  in  the  male.  In  hip  disease,  with  anchylosis 
of  the  hip  joint  in  the  flexed  position,  the  pelvis  as  a  whole  moves 
about  the  transverse  axis  passing  through  the  acetabula  and  its 
obliquity  is  increased  on  standing,  in  order  to  bring  the  anchylosed 
limb  into  a  vertical  position.  To  allow  of  this  increased  obliquitv  of 
the  pelvis  the  forward  convexity  of  the  lumbar  vertebrte  is  increased 
(lordosis)  by  their  extension.  Increased  obliquity  causes  a  protrusion 
of  the  belly,  a  flattening  of  the  adductor  region,  from  lengthening  of 
its  muscles,  and  a  backward  position  of  the  external  genitals.  The 
normal  obliquity  of  the  pelvis  may  be  shown  by  placing  tiie  anterior 
superior  iliac  spines  and  the  pubic  spines  in  the  same  vertical  plane,  as 
against  the  wall  (H.  v.  Meyer). 

The  inclination  of  the  pelvic  outlet,  or  the  angle  between  the  horizon 
and  the  line  connecting  the  tip  of  the  coccyx  w'ith  the  lower  border  of 
the  symphysis,  averages  12°  to  15°.  The  axis  of  the  inlet,  or  the  line 
at  right  angles  to  the  center  of  its  plane,  passes  obliquely  forward  and 
upward,  so  that  if  prolonged  it  would  meet  the  umbilicus  above  and 
the  middle  of  the  coccyx  below.  The  axis  of  tJie  outlet  prolonged 
upward  touches  the  base  of  the  sacrum,  and  prolonged  downward  is 
directed  slightly  backward,  whereas  the  curved  line  representing  the 
axis  of  the  entire  pelvis,  if  prolonged  downward,  would  curve  forward. 
This  distinction  is  not  always  understood.  The  axis  of  the  caviti/, 
nearly  straight  above,  more  curved  below,  is  parallel  to  the  curve  of 
the  sacrum  and  equidistant  from  all  sides  of  the  pelvis.  The  descent 
of  the  foetal  head  follows  this  curved  line,  turning  as  it  were  around 
the  symphysis  as  an  axis.  As  this  curved  axis,  continued  downward, 
passes  near  the  center  of  the  vulva,  those  cases  where  the  vulva  is  un- 
usually far  forward  are  more  exposed  to  rupture  of  the  perineum  in 
delivery.  It  is  also  in  this  curved  direction  that  instruments  (sounds, 
etc.)  are  passed  to  the  pelvic  viscera. 

With  a  normal  inclination  of  the  pelvis,  the  sacral  i)romontory  lies 
3|  inches  (9.5  cm.)  above  the  upper  border  of  the  symphysis  and  the 
tip  of  the  coccyx  one  half  to  one  inch  above  its  lower  border.  The 
long  axis  of  the  symphysis  forms  an  angle  of  100°  with  the  conjugate 
diameter  of  the  brim,  /.  e.,  the  line  between  the  promontory  or  sacro- 
vertebral angle  and  the  upper  end  of  the  symphysis.  This  fact  is  of 
importance  in  obstetrics,  as  the  fetal  head  makes  one  of  its  principal 
turns  around  the  symphysis. 

Obstetricians  consider  three  diameters,  ventro-dorsal  or  conjugate, 
transverse  and  oblique,  in  three  planes  of  the  pelvis,  that  of  the  brim, 
the  center  or  largest  part  of  the  cavity,  and  the  outh't.  The  oblitpic 
diameter  at  tiie  brim  is  between  the  sacro-iliac  joint  and  the  ilio-pubie 
eminence,  in  the  cavity  from  thr  middle  of  the  sacro-sciatic  notch  to 


352  PELVIS  AND  PERINEUM. 

the  obturator  foramen,  and  at  the  outlet  from  the  sacro-sciatic  ligament 
to  the  ischial  ramus.  The  transverse  diameter  at  the  outlet  is  the  dis- 
tance between  the  ischial  tuberosities.  The  measurements  of  the  diam- 
eters vary  according  to  age,  sex  and  individuality,  and  especially  in 
the  presence  of  pelvic  deformities.  In  the  female  the  conjugate, 
transverse  and  oblique  diameters  measure  in  inches  as  follows  :  at  the 
brim  4|,  5|,  5  +  ;  in  the  cavity,  5  +,  5,  5^;  at  the  outlet,  4|,^  4|, 
4^.  If  the  measurements  are  materially  diminished  symmetrically, 
as  in  a  case  of  "equally  contracted  pelvis,"  in  women  apparently  well 
formed,  or  unsymmetrically  in  rachitic  pelvic  deformities,  normal  labor 
may  be  rendered  difficult  or  impossible. 

The  apparently  greater  width  of  the  female  pelvis,  as  shown  by  the 
hips,  is  due  to  the  greater  amount  of  subcutaneous  fat  and  the  com- 
parison with  the  narrower  waist.  The  distance  between  the  anterior 
superior  spines  and  the  iliac  crests  of  the  two  sides  measures  about  the 
same  in  the  two  sexes,  though  many  authorities  give  the  latter  meas- 
urement greater  in  the  female,  while  Quain  gives  both  greater  in  the 
male.  The  true  pelvis  is  shallower,  broader  and  more  capacious  in  the 
female ;  the  false  pelvis  is  relatively  narrower  and  less  deep  in  the 
female  (Quain).  In  the  female,  too,  the  symphysis  is  less  deep  and  both 
the  subpubic  arch  and  the  distance  between  the  ischial  tuberosities  is 
much  wider,  all  of  which  are  of  importance  in  the  mechanism  of  labor. 

The  pelvis  as  a  whole  may  move  on  three  axes,  a  transv-erse  (flexion  and 
extension),  an  antero-posterior  (tilting),  or  a  vertical  (rotation).  These 
movements  take  place  in  the  lumbar  spine.  Flexion  and  extension  are 
the  most  important  and  the  most  extensive,  and  decrease  or  increase 
the  obliquity  of  the  pelvis,  respectively.  When  the  hip  joint  is  fixed 
or  anchylosed  it  is  the  pelvis  that  is  flexed  or  extended  on  the  trans- 
verse axis  passing  through  the  acetabula.  It  is  enabled  to  do  this  by 
movements  of  the  lumbar  spine  in  the  same  direction  (see  above,  p. 
351). 

Normally  the  pelvis  is  on  the  same  level  on  the  two  sides  so  that 
the  line  joining  the  two  anterior  superior  iliac  spines  is  horizontal  in 
the  erect  position.  Pathologically  this  line  may  be  oblique  so  that 
there  is  a  lateral  obliquity  or  tilting  of  the  pelvis  on  an  antero-posterior 
axis.  In  such  a  case  one  side  of  the  pelvis  is  raised  while  there  is  a 
lateral  curve  of  the  lumbar  vertebrae  toward  the  opposite  side  to  enable 
the  trunk  to  be  held  erect.  This  is  often  the  result  of  hip  disease, 
where  the  thigh  on  the  affected  side  may  be  fixed  in  the  ad-  or  abducted 
position,  and  the  pelvis  is  tilted  to  allow  the  limbs  to  hang  vertically 
in  standing  or  walking.  Or  it  may  result  from  a  shortened  limb,  from 
fracture  or  any  other  cause,  and  the  length  of  the  two  limbs  is  made 
apparently  and  often,  for  practical  purposes,  virtually  equal  by  the 
tilting  of  the  ])elvis  downward  on  the  side  of  the  shortened  limb. 

Before  illustrating  these  facts  it  is  well  to  notice  that  the  anterior 
superior  iliac  spines,  from  which  we  take  our  measurements  to  determine 
the  length  of  the  lower  extremities,  lie  lateral  to  the  acetabula.  Hence 
^  With  the  coccyx  pressed  backward. 


MEASUREMENT  OF  THE  LOWER   EXTREMITY. 


353 


we  measure  the  long  side  of  an  oblique-angled  triangle  of  which  the 
short  side  is  the  line  between  the  iliac  spine  and  the  acetabulum,  and 
the  third  side  is  the  lower  limb  itself.  If  the  tiro  HhxIjh  are  of  equal 
lengtli  and  one  is  fixed  at  the  hip  in  the  abducted  position,  the  otlier 
limb  to  be  parallel  with  it  must  l)e  adducted.  (Fig.  81,  ACM'  and 
A'CM".)  J5y  a  lateral  tilting  of  the  pelvis  both  limbs  are  made  appar- 
ently straight  and  in  the  long  axis  of  the  body.  (Fig.  82.)  The 
pelvis  on  the  abducted  side  is  lowered  by  the  tilting,  hence  its  aceta- 
bulum is  lower  than  that  of  the  opposite  side.  Therefore  the  limb 
on  the  abducted  side  will  appear  longer  (apparrnf  (riir/fhrniiif/)  than  that 
on  the  adducted  side,  which  cannot  touch  the  ground.  If,  however, 
we  measure  the  two  sides  we  are  surprised  to  find  that  the  abducted 
and  apparently  longer  limb  measures  less  (measured  shortmhtfj)  than 
the  other,  while  in  reality  the  two  are  exactly  equal  in  length. 


Fig.  81. 


Figs.  81  and  82.  Diagrams  to  show  the  correct  (81)  and  the  incorrect  (82)  position  for  nieaaure- 
ment  of  the  lower  extremity  and  the  elfects  of  aV>-  and  adduction  on  the  apparent  and  measured 
length  of  the  limb.s.  The  plain  lines  in  Fig.  81  show  the  correct  position  for  measurement,  the  crossed 
lines  represent  the  left  hand  limb  abducted,  the  right  adducted.  This  same  position  is  slnvwn  in  Fig. 
82  but  the  pelvis  is  tilted  to  bring  the  limbs  in  line  with  the  a.\is  of  tlie  body.  A,  anterior  superior 
iliac  spine;  (',  cotyloid  cavity;  V,  umbilicus,  M,  malleolus;  V,  point  cjuidistant 'from  the  two 
malleoli ;  VP,  line  from  this  pi'iint  to  the  umbilicus ;  AA,  line  connecting  the  two  iliac  spines  ;  AM, 
the  line  of  measurement  ;  CM,  the  real  length  of  the  limb ;  AC,  the  line  from  the  iliac  spine  to  the 
cotyloid  cavity. 

The  exphindtlon  is  simple.  As  one  limb  is  gradually  abducted  the 
triangle,  whose  long  side  we  measure,  approaches  more  nearly  a  right- 
angled  triangle  until  it  becomes  one,  hence  the  length  of  the  long 
side  we  measure  decreases  as  we  abduct  for,  the  two  sides  remain- 
iDg  the  same,  the  long  side  decreases  in  length  as  the  angle  decreases 
23 


354  PELVIS  AND  PERINEUM. 

from  an  oblique  angle  to  a  right  angle  and  vice  versa.  As  the 
other  limb  is  gradually  adducted  the  obtuse  angle  in  the  triangle  in- 
creases, so  that  the  long  side  measures  more  and  more  until  the  side 
representing  the  limb  is  in  line  with  the  short  side  of  the  triangle,  and 
then  the  line  we  measure  comprises  two  sides  of  the  triangle  which, 
according  to  a  rule  of  geometry,  are  greater  than  the  third  side.  (i^ig. 
82,  A'CM'.) 

Hence  we  see  that  abduction  decreases  measured  lengthening  and  ad- 
duction increases  it.  Therefore  in  measurements  to  determine  the  com- 
parative length  of  the  limbs  it  is  necessary  to  see  that  there  is  neither 
abduction  nor  adduction.  This  we  do  by  seeing  that  there  is  no  tilting 
of  the  pelvis  and  that  the  limbs  are  in  the  long  axis  of  the  body  or,  in 
practice,  that  the  line  connecting  the  anterior  superior  iliac  spines  (Fig. 
81,  AA')  is  at  right  angles  to  the  long  axis  of  the  body  (Fig.  81,  VP) 
and  that  the  latter  prolonged  is  equidistant  from  the  malleoli  of  the 
two  feet  to  which  we  measure  (Fig.  81,  MP-PM).  Or  stretch  a 
string  or  bandage  from  the  umbilicus  to  the  mid  point  between  the 
two  ankles  (Fig.  81,  VP)  and  see  that  this  is  at  right  angles  to  a  line 
connecting  the  two  anterior  superior  iliac  spines  (Fig.  81,  A  A). 

Another  anomaly  is  that  if  one  side  is  actually  a  little  shorter 
(actual  shortening)  and  the  pelvis  is  tilted,  the  short  limb  if  adducted 
may  appear  shorter  and  measure  longer  than  the  longer  limb  or,  if 
abducted,  it  may  appear  longer  and  measure  shorter.  When  the  pelvis 
is  tilted  the  limb  on  the  lower  side  is  always  abducted  and  vice  versa. 
Actual,  measured  and  apparent  shortening  do  not  coincide  unless  there 
is  no  tilting  of  the  pelvis.  If  one  limb  is  a  little  shorter  as  a  result  of 
fracture  of  the  femur,  old  hip  trouble  with  loss  of  substance  of  the 
head,  excision  of  the  hip  or  knee  joint,  etc.,  it  may  be  made  of  equal 
length  with  the  other,  to  all  appearances  and  for  all  practical  purposes, 
by  tilting  the  pelvis  down  on  the  short  side  and  up  on  the  long  side. 
The  slightly  shorter  limb  would  appear  equal  but  measures  consider- 
ably shorter.  Thus  fracture  of  the  femur  with  an  inch  or  so  shortening 
may  be  compensated  for  by  such  a  slight  tilting  of  the  pelvis  that  it  is 
scarcely  noticed  and  produces  no  awkwardness  of  gait.  The  pelvis 
may  also  be  rotated  on  a  vertical  axis  so  that  one  anterior  superior  iliac 
spine  is  in  advance  of  the  other.     This  may  also  occur  in  hip  disease. 

The  Lining  of  the  Pelvis. 

Pelvic  Floor  or  Diaphragm. — At  the  sides  of  the  pelvis  the  is- 
chium, the  obturator  membrane,  and  the  bony  margins  bounding  it 
are  well  padded  by  the  thick  obturator  internus  muscle.  At  the 
back  of  the  pelvis  is  the  pyriformis  on  either  side,  while  tlie  outlet  is 
occupied  by  the  coccygeus  behind  and,  in  front  of  this,  by  the  levator 
ani.  These  latter  two  muscles,  especially  the  levator  ani,  form  the 
sagging  /foor  or  diaphragm  of  the  pelvis  and  separate  its  cavity  from 
the  perineum  in  front  and  the  ischiorectal  fossa  behind. 

The  anterior  border  of  the  levator  ani  descends  along  the  side  of 
the  prostate  and  some  of  its  fibers  unite  beneath  it  with  those  of  the 


OBTURATOR  HERNIA.  355 

opposite  side  at  the  central  tendinous  point  of  the  perineum,  where 
they  blend  with  the  external  sphincter  ani  and  the  transversus  peri- 
nei  muscles.  The  posterior  fibers  of  the  levator  ani  are  attaciied  to  the 
tip  of  the  coccyx.  The  rectum  in  both  sexes  and  the  vagina  in  the 
female  perforate  in  the  median  line  the  pelvic  Hoor,  formed  by  the 
levator  ani,  and  at  these  points  the  fibers  of  the  muscle  interlace 
with  the  longitudinal  muscle  fibers  of  the  walls  of  those  organs,  more 
intimately  with  those  of  the  rectum.  Elsewhere  in  the  median  line 
the  levator  ani  is  attached  to  the  median  fibrous  yv/y>/u',  extending  from 
the  coccyx  to  the  rectum  and  thence  to  the  central  tendinous  point  of 
the  perineum.  gp^v    . 

Besides  the  openings  for  the  rectum  and  vagina  there  are  several 
srmaJl  ojX')iiiif/.s  in  the  pelvic  walls  for  the  pa-snarje  of  vessels  and  nerves: 
(1)  through  the  (jreat  sciatic  notch,  above  the  pyriformis,  for  the 
superior  gluteal  vessels  and  nerves;  (2)  through  the  great  sciatic  notch 
between  the  pyriformis  and  the  coccygeus  for  the  internal  pudic  and 
sciatic  vessels  and  nerves  and  the  inferior  gluteal  vessels  ;  (3)  through 
the  obturator  foramen  above  the  internal  obturator  muscle  for  the  ob- 
turator vessels  and  nerves.  The  gap  in  the  pelvic  floor  between  the 
levator  ani  muscles  in  front  is  filled  by  the  triangular  ligament,  which 
is  pierced  by  the  urethra  and,  above  it,  by  the  dorsal  vein  of  the  penis, 
or  the  corresponding  vein  in  the  female. 

Pelvic  Herniae. — Through  the  first  two  foramina  above  mentioned 
two  of  the  forms  of  pelvic  hernise  occur. 

Obturator  hernia  occurs  through  the  obturator  canal,  which  is 
directed  downward,  forward  and  inward  beneath  the  horizontal  ramus 
of  the  pubis  for  about  2  cm.,  with  a  diameter  of  1  to  1^-  cm.  Such  a 
hernia  pushes  a  sac  of  pelvic  peritoneum  before  it  and  sometimes  the 
obturator  fascia.  It  comes  to  lie  deepli/  beneath  the  pectineus  and 
adductor  longus  muscles,  by  separating  which  it  may  be  exposed  through 
an  incision  near  the  inner  border  of  Scarpa's  triangle.  It  is  often  best 
to  reach  it  by  abdominal  incision  above  the  pubes.  The  obturator 
vessels  and  nerves  are  usually  on  the  outer  side  or,  next  most  com- 
monly, the  nerve  may  be  in  front  and  the  artery  behind.  The 
proximity  of  the  nerve  renders  peripheral  pain  from  pressure  a  con- 
spicuous symptom,  which  lias  misled  surgeons  into  treating  it  for  some 
other  condition.  As  the  hernia  lies  on  the  mesial  side  of  the  hip  cap- 
sule pain  on  moving  the  hip  is  often  a  marked  symptom.  Obturator 
hernise  generally  occur  in  advanced  age  and  much  more  commonly  in 
females,  in  whom,  it  is  well  to  note,  the  inner  orifice  of  the  canal  can 
be  examined  through  the  vagina.  It  is  too  deeply  situated  to  l)e 
evident  in  Scarpa's  triangle  and  may  best  be  detected  by  the  finger 
along  the  pubic  ramus  and  behind  the  adductor  longus,  while  the 
thigh  is  flexed,  adductcd  and  rotated  out,  or  by  vaginal  or  rectal  ex- 
amination.     Strangulation  is  the  rule. 

Ischiatic  hernia,  escaping  tlu\)ugh  the  great  sciatic  foramen,  above 
or  below  the  j)yrilormis,  lies  beneath  the  gluteus  maximus  muscle.  It 
is  rare. 


356  ,    PELVIS  AXD  PERINEUM. 

Other  rare  forms  of  hernise  occur  through  the  pelvic  floor,  whose 
starting  point  we  know  only  imperfectly.  They  occur  in  adults, 
usually  in  women,  and  on  one  side  of  the  median  line.  The  sac, 
covered  by  the  rectovesical  fascia,  escapes  through  the  fibers  of  the 
levator  ani  muscle  to  appear  in  the  posterior  part  of  the  labium  majus 
(pudendal  hernia),  in  the  perineum  (perinea/  hernia),  in  the  ischio- 
rectal fossa  (ischiorectal  hernia)  or  in  the  vagina  {vaginal  liernia).  A 
rare  form  of  hernia,  whose  sac  is  covered  on  one  side  by  the  rectal 
wall,  may  appear  outside  of  or  just  within  the  sphincter  ani  muscle  (rectal 
hernia).  In  perineal  hernia  the  sac  escapes  in  front  of  the  rectum  be- 
tween it  and  the  vagina  or  prostate,  and  in  pudendal  hernia  it  escapes 
between  the  ischial  ramus  and  the  vagina. 

Pelvic  Fascia.  (Fig.  84.) — The  muscles  of  the  walls  and  floor  of 
the  pelvis  are  lined  by  a  fascia,  the  pelvic  fascia.  This  helps  to  form 
a  sheath  for  the  muscles  and  to  separate  more  effectually  the  pelvic 
cavity  from  the  perineum  and  ischiorectal  fossa,  and  it  serves  to 
strengthen  and  support  the  pelvic  viscera  by  its  reflections  onto  them. 
Certain  parts  of  these  reflections  onto  the  viscera  are  called  their  true 
ligaments,  in  the  case  of  the  bladder,  etc.  Two  principal  portions  are 
distinguished,  a  parietal  and  a  visceral. 

The  parietal  portion,  or  obturator  fascia,  lines  the  obturator  internus 
and  is  contimious  with  the  iliac  and  trans versalis  fasciae  at  the  pelvic 
brim,  along  which  it  is  attached.  It  is  also  attached  to  the  free  border 
of  the  ischium,  the  falciform  process  of  the  great  sacrosciatic  ligament, 
and  the  inner  lip  of  the  lower  border  of  the  ischiopubic  ramus.  At 
the  latter  attachment  it  is  continuous  on  either  side  with  the  deep  layer 
of  the  triangular  ligament.  The  obturator  fascia  forms  a  fibrous  canal 
for  the  internal  pudic  vessels  and  nerves.  Along  a  line  from  the  back 
of  the  pubis  to  the  ischial  spine  the  levator  ani  is  attached  to  this 
fascia,  which  is  here  thickened  and  hence  appears  white  (the  lohite  line). 
The  obturator  fascia  above  this  line  is  sometimes  distinguished  as  the 
^'  pel  ric  fascia.^' 

From  this  white  line  is  given  ofi'  the  visceral  portion,  or  rectovesical 
fascia,  which  lines  the  upper  or  pelvic  aspect  of  the  levator  ani  muscle 
and  is  reflected  onto  the  pelvic  viscera  where  they  penetrate  this  muscle, 
i.  e.,  rectum  and  vagina,  and  onto  those  immediately  related  to  the  pel- 
vic floor,  bladder,  prostate,  seminal  vesicles  and  uterus.  From  the 
lower  end  of  the  bladder  it  is  reflected  down  to  form  the  fihrous  capsule 
of  the  prostate,  at  the  apex  of  which  it  is  continuous  with  the  deep  layer 
of  the  triangular  ligament.  It  thus  encloses  the  vesicoprostatic  plexus 
of  veins.  From  either  side  of  the  symphysis  a  fold  of  this  fascia,  cov- 
ering a  small  bundle  of  muscle  tissue  prolonged  from  the  bladder 
(vesicopul)ic  muscle),  passes  back  to  the  prostate  and  bladder  as  the 
anterior  true  ligaments  of  the  bladder  (puboprostatic  ligaments).  In  the 
depression  between  the  latter  the  pelvic  fascia  is  thin  and  through  it  is 
seen  a  plexus  of  veins,  connected  with  the  dorsal  vein  of  the  penis,  which 
lies  beneath  the  plexus.  The  fold  from  either  side  of  tiie  pelvis  to  the 
sides  of  the  bladder,  the  lateral  true   ligaments  of  the  bladder,  are 


PLATE   XLI 


FIG.  8S. 


OBTURATOR 
VESSELS 

AND    N  ERVt 


^^t-WHITE   LINC 


Pelvic  floor  in  the  iTiale.  The  fascia  is  in  place  on 
left  and  is  renioved  on  right  side.  The  dotted  line 
outlines  the  bony  outlet  of  the  pelvis.     (Testut.) 


FIG.  84. 


-.-- 


^.''''■'■•.'■^•'<^'','-''^Jf*^i. 


PELVIC    PORTION 
OF   OBTURATOR 
FASCIA 


OBTURATOM 
MEMBRANE 


ISCHIO-CAVER 
MUSCL 


lO-RECTAL    FOSSA 
NTERIOR    EXTEN- 
ON  ' 


TRIANCU 

MENT     DEEP  LAYER 


LAYER 
SUPERFICIAL 
PERINEAL 
FASCIA. 
DEEP  LAYER 


Frontal  section  of  the  pelvis  thi-ough  the  middle  of  tlie 
ischiopubic  rami;  partly  diagrammatic,  to  show  the 
pelvic  fasciae.  Anterior  segment  of  the  section  viewed  from 
iDchind.    The  fasciae  are  in  l^lue.     (Testut.) 


PELVIC  FASCIA.  357 

scarcely  demonstrable.  Further  back  the  fascia  passes  across  between 
the  bladder  and  rectum,  uniting  yet  separating  tliem  in  the  trigonal 
area  and  investing  the  seminal  vesicles.  The  lower  end  of  the  rectum 
also  receives  a  thin  prolongation  of  the  fascia. 

Behind  the  levator  ani  the  rectovesical  and  obturator  fasciie  are  con- 
tinuous and  cover  the  pelvic  aspect  of  the  coccygeus  and  pyriformis 
muscles.  At  the  anterior  border  of  the  levator  ani  the  rectovesical 
fascia  above  it  joins  the  anal  fascia  beneath  it  and  is  continued  forward 
to  the  obturator  fascia,  or  its  prolongation  the  deep  layer  of  the  tri- 
angular ligament. 

The  reflections  and  attachments  of  the  rectovesical  fascia  exclude  cer- 
tain viscera,  or  parts  of  viscera,  from  tlte  pelvic  cavibj,  i.  c,  the  prostate, 
seminal  vesicles,  trigone  and  outlet  of  the  bladder  and  the  lower  2h  to 
3  inches  of  the  rectum.  These  may  be  wounded  without  entering  the 
pelvic  cavity  and,  provided  their  fascial  sheath  is  intact,  suppuration 
in  them  would  tend  to  spread  towards  the  perineum  and  not  into  the 
pelvis.  On  the  rectum  the  fascia  reaches  some  little  way  below  the 
rectovesical  pouch  of  peritoneum  in  front.  The  pelvic  rcwcAs  are  on  the 
inside  of  the  fascia,  the  nerves  of  the  sciatic  and  lumbar  plexuses  on  the 
outside.  The  vessels,  excepting  the  obturator,  must  pierce  the  fascia 
to  get  out  of,  the  nerves  to  get  into  the  pelvic  cavity  and  through  these 
small  openings  inflammation  may  possibly  spread.  But  as  a  rule  supjpur- 
ation  above  the  fascia  is  limited  to  the  pelvic  and  abdominal  cavity,  that 
below  to  the  perineum  and  ischiorectal  fossa.  Wounds  of  the  latter  two 
regions  that  involve  this  fascia  have  the  added  danger  of  pelvic  inflam- 
mation ;  hence  is  seen  the  surgical  importance  of  the  pelvic  fascia. 

Between  the  pjeritoneum,  which  lines  part  of  the  pelvic  floor  and 
covers  most  of  the  pelvic  viscera,  and  the  ''pelvic"  and  rectovesical 
fasciae  is  a  continuous  layer  of  loose  subperitoneal  connective  tissue 
in  which  inflammation  may  spread  readily  and  widely  and  lead  to 
suppuration.  This  tissue  is  found  most  aljundantli/  between  the  ante- 
rior bladder  wall  and  the  pelvis  and  about  the  outlet  of  the  bladder 
and,  in  the  female,  about  the  lower  part  of  the  uterus  and  the  upper 
end  of  the  vagina  and  between  the  folds  of  the  broad  ligament.  In- 
flammation and  sup})uration  in  this  tissue,  known  as  pelvic  cellulitis,  is 
prevented  from  escaping  through  the  pelvic  floor  by  the  pelvic  fascia. 
Hence,  as  this  tissue  is  continuous  with  the  subperitoneal  tissue  of  the 
iliac  fossa,  the  abscess  usually  passes  up  over  the  pelvic  brim  to  the 
iliac  fossa  and  j)oint.'<  in  the  inguinal  region  (q.  v.).  Barely  it  may 
open  into  one  of  the  pelvic  viscera  or  into  the  peritoneal  cavity.  In 
the  male  it  may  follow  the  vas  deferens  to  the  inguinal  canal  and 
scrotum.  //(  tromen  the  inflammation  and  abscess  are  often  found 
Mithiu  the  broad  ligaments  or  beneath  the  i)eritoneum  lining  Douglas' 
pouch,  i)etween  the  uterus  and  rectum.  Clinically  pelvic  cellulitis  is 
often  accompanied  by  an  inflammation  of  the  jielvic  porit(»iU'um,  jnlvio 
peritonitis  ;  the  latter  may  also  occur  separately. 

In  pelvic  hematocele  the  blood,  if  intraperitoneal ,  may  trickle  into 
Douglas'   pouch,  where   it  may  become  enclosed  by   peritoneal  adhe- 


358  PELVIS  AND  PERINEUM. 

sions  ;  or,  if  subperitoneal,  it  collects  most  often  between  the  layers  of 
the  broad  ligament.  It  often  comes  from  a  ruptured  varicose  ovarian 
vein.  Pressure  of  the  mass  on  the  rectum  may  cause  tenesmus. 
These  collections  of  blood  may  of  course  become  infected  and  sup- 
purate and  in  such  a  case  can  be  opened  through  the  vagina. 

THE    VISCERA    OF    THE    PELVIS. 

The  Rectum. 

As  stated  above  (see  Sigmoid  Flexure,  p.  317)  that  part  of  the 
rectum,  formerly  called  the  first  portion,  which  is  provided  with  a 
mesentery  and  extends  from  the  left  sacro-iliac  joint,  at  the  pelvic  brim, 
to  the  middle  of  the  third  sacral  vertebra,  is  now  considered  as  a  por- 
tion of  the  sigmoid  loop,  with  which  it  is  continuous.  Between  the 
layers  of  the  mesentery  of  this  portion  of  the  sigmoid  run  the  inferior 
mesenteric  vessels  which  divide,  where  the  mesentery  ends,  into  the  two 
sets  of  bilateral  superior  hemorrhoidal  vessels. 

The  rectum  thus  limited  is  more  entitled  to  its  name,  rectum  (straight), 
as  it  is  not  curved  laterally,  only  antero-posteriorly.  Of  the  two  parts 
into  which  it  is  naturally  divided  the  upper  or  jjelvic  portion,  3|  inches 
long,  follows  the  curve  of  the  sacrum  and  coccyx,  upon  which  it  lies  ; 
the  lower  or  anal  portion  bends  backward  and  downward  just  below  the 
tip  of  the  coccyx.  It  is  important  to  bear  in  mind  the  direction  of  the 
tivo  curves  in  examining  or  passing  instruments  into  the  rectum.  The 
axis  of  the  anal  portion  if  continued  meets  the  prostate  near  its  apex  or 
the  rectovaginal  septum.  Hence,  in  introducing  a  bougie,  the  nozzle  of 
a  syringe,  a  speculum,  etc.,  the  instrument  should  first  follow  the  axis  of 
the  anal  portion  for  1|  inches,  upward  and  forward,  and  then  be  tilted 
so  that  its  upper  end  is  directed  upward  and  backward  in  the  curve  of 
the  upper  part. 

The  dividing  line  between  these  two  parts  corresponds  about  to  the 
point  where  the  rectum  pierces  the  pelvic  floor.  The  anal  portion  is 
therefore  entirely  extra-pelvic  and,  by  the  manner  of  the  reflection  of 
the  pelvic  fascia  (see  above,  page  357),  the  lower  part  of  the  upper 
portion  is  also  extra-pelvic.  In  infants  the  lower  end  of  the  large  gut 
is  straighter  and  more  or  less  vertical,  and  the  upper  part  of  what  was 
formerly  called  the  first  portion  of  the  rectum  is  in  the  abdominal  cavity. 
On  account  of  its  more  vertical  position  in  childhood,  together  with 
its  loose  connections,  the  small  size  of  the  prostate  and  the  liability  to 
such  exciting  causes  as  worms  and  rectal  polypi,  prolapsus  ani  is  espe- 
cially common  at  this  age. 

The  Pelvic  Portion. — Above  the  anal  portion  the  rectum  is  dilated 
into  a  large  ampulla  extending  forward  to  the  apex  of  the  prostate, 
and  backward  to  the  coccyx.  This  part  is  very  distensible  and,  in 
cases  of  faecal  accumulation,  may  be  enormously  distended.  Curious 
foreign  bodies  of  large  size  have  been  found  in  this  ampulla  such  as,  for 
instance,  a  bottle  (Desormeaux),  a  glass  tumbler  and  an  iron  match 
box.     When   this  portion   of  the   rectum   is   distended,   in    the   male. 


RELATIONS  TO   THE  PERITONEUM.  359 

the  bladder  is  raised  and  pushed  forward  and  the  rectovesical  pouch  of 
peritoneum  is  elevated.  Adv;intaf2:e  has  been  taken  of  this  fact  in 
suprapubic  cystotomy  by  distending  the  rectum  by  a  rubber  bag,  inflated 
with  air  or  water,  to  help  raise  the  bladder  above  the  symphysis. 

This  portion  is  large  enour/li  to  contain  the  entire  hand  which  mav  be 
introduced,  if  not  over  eight  inches  in  diameter,  after  a  gradual  dilata- 
tion of  the  sphincters  under  anjusthesia.  By  a  semi-rotary  movement 
it  can  be  insinuated  into  the  lower  end  of  the  sigmoid  loop.  It  is  said 
that  a  large  part  of  the  abdomen  may  be  thus  examined,  even  as 
far  as  the  kidneys,  owing  to  the  movability  of  the  part.  Yet  the 
practice  is  dangerous  as  the  bowel  may  be  torn,  especially  that  |)art 
covered  by  peritoneum,  and  the  sphincter  may  be  permanently  para- 
lyzed. Moreover  the  practical  results  are  unsatisfactory  owing  to  the 
cramping  of  the  hand.  By  means  of  a  wooden  lever,  invented  by  Mr. 
Davy,  introduced  into  the  rectum,  the  common  iliac  vessels  have  been 
compressed  against  the  pelvic  brim  to  arrest  hemorrhage  in  amputation 
at  the  hip  joint. 

Attachments. — Although  the  rectum,  in  passing  through  the  pelvic 
floor,  receives  an  attachment  from  the  pelvic  fascia,  this  fascia  is  not 
so  firm  but  that  in  rare  cases  all  the  walls  of  the  gut  are  prolapsed  at 
the  anus.  This  mobility  of  the  rectum  is  of  use  in  excision  of  its  lower 
part,  for  it  allows  the  upper  part  to  be  drawn  down  so  as  to  be  sutured 
to  the  skin  or  the  edges  of  a  healthy  anal  segment.  In  order  to  free  it 
for  removal  the  levator  ani  mu.sclc,  some  of  whose  fibers  are  prolonged 
into  and  sup[)ort  the  bowel,  is  divided.  To  allow  the  upper  part  to  be 
pulled  down  the  peritoneal  attachment  must  be  loosened.  This  may  be 
done  by  carefully  stripping  up  the  peritoneum  from  oflP  the  front  and 
sides  of  the  rectum  and  then  by  dividing  the  mesentery  of  the  lower 
sigmoid  on  either  side,  taking  care  to  avoid  the  blood  vessels,  which 
run  superficial  to  the  muscle  layers,  for  injury  to  these  vessels  means 
gangrene  of  the  upper  segment. 

The  rectum  is  loosely  attached  by  loose  connective  tissue  to  the  lower 
half  of  the  sacrum  and  the  coccyx,  while  in  front  it  is  more  closely 
attached  to  the  back  of  the  y>/-o.s^«^e  and  bladder  by  firmer  connective 
tissue,  the  prostato-peritoneal  aponeurosis,  connected  with  the  rectoves- 
ical fascia.  This  aponeurosis  however  allows  the  separation  of  the 
rectum  from  the  prostate  and  bladder  and,  if  traced  u]iward,  is  found 
to  be  attached  to  the  bottom  of  the  rectovesical  ]>ouch  of  the  i)eritoneum. 
///  the  female  the  rectum  is  attaciied  to  the  vagina  in  front  by  a  con- 
siderable amount  of  looser  connective  tissue. 

The  relations  of  the  rectum  have  a  twofold  importance,  first  in 
diseases  of  or  operations  on  the  rectum,  second  because  rectal  exami- 
nation is  of  the  greatest  importance  in  determining  the  condition  of  the 
organs  in  relation  to  it. 

Relations  to  the  Peritoneum. — Commencing  op|x>sito  the  third 
sacral  vertebra  there  is  no  mesorectum  but  the  peritoneum,  at  first 
covering  the  front  and  sides  of  the  bowel,  is  reflected  from  tiie  sides 
along  an  oblique  line  descending  from  behind  forwanl.      It  is   finally 


360  PELVIS  AND  PERINEUM. 

reflected  from  the  front  of  the  rectum  onto  the  bladder  in  the  male  and 
onto  the  vagina,  cervix  and  uterus  in  the  female,  forming  the  7'ecto- 
vesical  and  rectovaginal  pouch  (Douglas'  pouch)  respectively.  The.  dis- 
tance of  the  rectovesical  pouch  from  the  anus  is  of  importance  in  rectal 
operations  and  measures  3  inches,  or  somewhat  more,  when  the  bladder 
is  empty,  and  as  much  as  4  inches  when  it  is  full.  The  distance  of 
the  similar  pouch  in  the  female  (Douglas'  pouch)  from  the  anus  is 
somewhat  less. 

In  complete  prolapse  of  the  rectum  of  large  size  this  peritoneal 
pouch  may  be  protruded  and  may  contain  coils  of  intestine,  which  oc- 
cupy it  in  the  normal  condition.  On  the  posterior  rectal  loall  the  peri- 
toneum does  not  come  within  five  inches  of  the  anus.  Thus  ulcers  and 
carcinomata  situated  anteriorly  are  more  likely  to  invade  the  peritoneal 
cavity  and,  in  excisions  of  the  rectum,  more  of  the  bowel  may  be 
readily  excised  posteriorly  than  anteriorly.  But,  as  we  have  seen,  in 
the  absence  of  inflammatory  adhesions  we  may  detach  from  the  peri- 
toneum and  draw  down  the  rectum  as  far  as  the  commencement  of  the 
mesentery,  where  the  peritoneum  encloses  the  bowel.  Above  this  point 
the  bowel  may  be  freed  by  dividing  the  peritoneum  of  the  mesentery 
on  either  side,  taking  care  not  to  injure  the  blood  vessels. 

By  rectal  examination  in  the  female  we  can  feel  anything  abnormal, 
like  a  prolapsed  ovary  or  a  retroflexed  uterus,  occupying  Douglas' 
pouch,  or,  in  the  absence  of  these,  we  can  feel  the  uterus  in  front  and 
the  ovaries  at  the  sides,  if  the  latter  are  enlarged  or  displaced.  The 
retroflexed  or  retroverted  uterus  may  so  press  upon  the  rectum  as  to 
favor  constipation,  cause  tenesmus,  and  set  up  inflammatory  or  con- 
gestive conditions  in  the  rectum  and  an  adhesion  of  the  opposed  peri- 
toneal surfaces  of  the  pouch.  The  close  relation  of  the  vagina  and 
anterior  rectal  wall  accounts  for  the  tears  into  the  rectum  at  childbirth. 
The  foetal  head  has  occasionally  been  forced  through  the  thin  recto- 
vaginal wall  and  delivered  per  rectum. 

Below  the  rectovesical  pouch  in  the  male  we  can  feel  the  bladder, 
corresponding  to  the  trigone,  judge  of  its  distension  and  occasionally 
feel  a  calculus  when  present  in  the  bladder.  Through  the  triangular 
area  of  the  bladder  in  contact  with  the  rectum,  and  below  the  peri- 
toneal pouch,  the  distended  bladder  was  formerly  punctured  by  a  trocar 
but,  owing  to  the  danger  of  infection,  this  method  has  been  superseded 
by  the  suprapubic  puncture.  Bounding  the  two  sides  of  the  triangular 
area  are  the  seminal  vesicles  and  the  vas  deferens.  These  can  be 
readily  felt  when  diseased  (tubercular)  or  distended,  not  readily  when 
normal.  In  violent  attempts  at  defecation  they  may  be  pressed  upon 
by  the  fecal  masses  and  partly  emptied,  producing  a  mechanical  form 
of  spermatorrhoea.  Massage  of  the  seminal  vesicles  as  a  therapeutic 
measure  has  been  practiced  through  the  rectum.  A  stone  impacted  in 
the  lower  end  of  the  ureter  may  possibly  be  felt  through  the  rectum. 

Below  the  palpable  area  of  the  bladder  and  seminal  vesicles  we 
readily  feel  the  posterior  surface  of  the  prostate  whose  apex,  1|  inches 
from  the  anus,  is  in  front  of  the  ampulla  at  the  lower  end  of  the  upper 


PLATE   XLI  I. 


FIG.  85. 


Sagittal  section  of  the  lower  pai-t  of  a   male  trunk,  the 
right  segment.     (Geri-ish,  after  Tesiut) 


STRUCTURE  OF  THE  RECTUM.  361 

portion  of  the  rectum.  By  rectal  palpation  we  can  feel  the  changes 
of  size,  shape,  consistency  and  sensitiveness  in  hypertrophy,  inflamma- 
tion and  abscess  of  the  prostate.  The  enlarged  prodate  naturally  pro- 
jects into  the  rectum  and,  when  of  very  large  size,  may  cause  obstruction 
to  the  passage  of  feces.  We  can  thus  appreciate  why  defecation  is 
painful  in  prostatitis,  etc.  At  this  part  too  a  prostdtic  almresH  ynni/ 
open  into  the  rectum,  and  such  an  opening  may  result  in  a  urethro- 
rectal fistula. 

Below  and  in  front  of  the  apex  of  tlie  prostate  can  be  felt  the  mem- 
branous urethra  especially  when  occupied  by  a  sound.  The  forefinger 
in  the  rectum  with  its  tip  at  the  apex  of  the  prostate  is  used  as  a 
guide  in  Cock's  operation  (perineal  section),  and  is  useful  in  many 
perineal  operations  on  the  urethra,  prostate,  etc.,  and  even  in  passing 
a  urethral  instrument  in  difficult  cases. 

The  bo)iy  points  ])alpablc  by  rectal  examination  have  been  mentioned 
(p.  346).  Their  palpation  is  of  use  in  determining  the  presence  of  any 
fracture,  disease  or  new  growth  connected  with  them.  It  is  well  to 
remember,  in  examining  for  suspected  lesions  high  up  in  the  rectum, 
that  by  having  the  patient  strain  as  at  stool,  especially  in  the  standing 
position,  one  to  two  inches  more  of  the  rectum  can  be  palpated  than 
otherwise. 

The  rectum  is  not  properly  a  reservoir  for  feces,  and  in  the  healthy 
condition  the  presence  of  the  latter  stimulate  it  to  contract.  In  some 
cases,  especially  those  subject  to  habitual  constipation,  it  may  contain 
a  large  amount  of  feces,  as  often  made  out  by  digital  examination,  the 
nerves  and  muscles  having  become  degenerate  and  ceasing  to  act. 

The  anal  or  terminal  portion  1^  inches  long,  is  the  narroivest  part 
of  the  large  intestine  though  very  dilatable.  It  is  quite  distinct  in  its 
surgical  relations  from  the  pelvic  portion.  The  internal  sphincter  sur- 
rounds it  while  the  levator  ani  and  its  enclosing  fasciae  are  attached  to 
and  support  its  sides,  which  are  in  relation  to  the  ischiorectal  fossne. 
In  front  lies  the  perineal  body  in  the  female,  separating  it  from  the 
lower  end  of  the  vagina,  and  the  perineum  in  the  male,  sej)arating  it 
from  the  urethra.  In  the  female  the  urethra  is  separated  from  it  i)y 
the  vagina  and  perineal  body. 

In  the  male  the  anal  portion  forms  the  posterior  wall  of  a  triangle  of 
which  the  perineum  forms  the  base  and  the  membranous  portion  of  the 
urethra,  where  it  adjoins  the  rcctiun,  the  apex.  Through  this  triangle 
are  made  the  various  perineal  incisions  by  which  the  bladder  or  pos- 
terior urethra,  and  sometimes  the  prostate  and  seminal  vesicles,  are 
reached. 

Structure  of  the  Rectum. — The  longitudinal  muscle  fibers  are  more 
uniformly  spread  out  than  in  the  rest  of  the  large  intestine  though,  accord- 
ing to  some,  the  three  bands  are  continued  as  two  bands,  one  in  front 
and  one  behind,  which  broaden  as  they  descend.  Tiie  circular  fiberx 
are  abruptly  thickened  (to  3  or  4  mm.)  in  the  upi>er  inch  of  the  anal 
portion  to  form  the  internal  sphincter.  The  lower  litnif  ot  the  anal  por- 
tion  is  represented  on   its  interior   by  a  circular  "  "///Vc  ///(r "  which 


362  PELVIS  AND  PERINEUM. 

marks  the  junction  of  the  skin  and  raucous  membrane.  The  external 
sphincter,  surrounding  the  anal  orifice,  is  a  striped  or  voluntary  muscle. 

The  looseness  of  the  submucous  tissue  is  such  as  to  allow  the  raucous 
membrance  to  be  protruded  or  prolapsed  at  the  anus  on  prolonged 
straining  at  stool  or  micturition.  The  greater  looseness  of  this  tissue 
in  infants  and  children  and  the  frequency  of  straining  attending  phi- 
mosis, constipation  or  the  irritation  of  worms  and  polypi,  makes  this 
accident  especially  frequent  in  early  life.  It  may  also  be  due  to  the 
relaxation  of  the  parts  attending  persistent  diarrhoea.  When  small  it 
involves  only  the  mucous  membrane  and  tends  to  re-ascend,  but  may 
be  held  down  by  an  irritated  sphincter.  When  large  all  the  coats  of 
the  bowel  are  apt  to  be  involved  and  the  rectovesical  peritoneal  pouch, 
and  even  coils  of  intestine,  may  be  contained  in  the  prolapse. 

Certain  obliquely  transverse  folds  of  mucous  membrane,  "  Houston's 
folds"  or  "  valves,"  not  effaced  by  the  distension  of  the  rectum,  are  of 
importance,  for  they  may  impede  the  passage  of  a  bougie  or  a  rectal 
tube,  especially  if  the  rectum  is  empty.  Hence  in  giving  a  high 
enema  first  fill  the  rectum  with  fluid  and  then  these  folds  will  not 
impede  the  passage  of  the  tube.  Three  such  folds  are  usually  pres- 
ent. One,  the  largest,  on  the  right  and  anterior  aspect  is  near  the 
rectovesical  pouch  of  peritoneum,  or  about  3  inches  from  the  anus,  and 
projects  I  to  f  inch  into  the  lumen  of  the  gut,  extending  around  half 
of  its  circumference  or  more.  It  has  been  described  as  the  third  or 
upper  sphincter.  The  other  two  are  to  the  left,  above  and  below  the 
former,  and  the  three  are  so  arranged  as  to  form  a  kind  of  spiral  valve. 

In  the  anal  portion,  coramencing  just  above  the  orifice,  are  several 
(3  to  8)  longitudinal  columns  or  folds  of  raucous  membrane,  |^  to  ^  inch 
long,  due  probably  to  bands  of  the  muscularis  mucosae.  Between  the 
lower  ends  of  these  colurans  are  semilunar  folds  or  valves  whose  up- 
turned concavities  form  little  sinuses.  These  are  the  columns,  valves 
and  sinuses  of  Morgagni.  Upon  these  columns  are  to  be  seen  little  pro- 
trusions, due  to  hemorrhoidal  veins. 

The  raucous  raerabrane  is  liable  to  dysenteric  inflammation  and  ulcer- 
ation and  the  cicatrization  of  the  ulcers  may  produce  stricture.  The 
liability  to  ulceration  is  greater  the  nearer  the  anus.  As  the  epi- 
thelium of  the  anus  is  squamous  and  that  of  the  rectum  columnar  an 
epithelial  neoplasm  of  the  former  is  an  epithelioma  (squamous  celled 
carcinoma)  and  of  the  latter  a  carcinoma  or  columnar  epithelioma. 

Vessels. — The  arteries  of  the  rectum  are  from  three  principal  sources, 
the  inferior  mesenteric,  the  internal  iliac  and  the  internal  pudic. 
The  branches  of  the  two  lateral  trunks  of  the  superior  hemorrhoidal 
pierce  the  muscular  wall  about  three  inches  from  the  anus  to  form  a 
longitudinal  network  in  the  submucous  tissue.  Hence  incisions  here 
should  be  lengthwise  to  avoid  profuse  bleeding.  The  arteries  com- 
municate freely  in  a  plexiforra  raanner  near  the  anus  and  more  or  less 
above.  Although  the  veins  have  the  same  plexiforra  arrangeraent  in 
the  subraucous  tissue  of  the  lower  rectura  and  take  the  sarae  course, 
7iiost  of  the  blood  is  relumed  by  the  superior  hemorrhoidcd  to  the  inferior 


THE  NERVE  SUPPLY  OF  THE  RECTUM.  363 

mesenteric  vein.  Hence  congestion  of  the  so-called  hemorrhoidal  veins 
of  the  rectum  is  apt  to  follow  portal  congestion  as  well  as  venous  con- 
gestion due  to  diseases  of  the  heart,  lungs,  etc. 

In  addition  to  these  causes  the  tendency  to  varicosities  of  the 
hemorrhoidal  veins,  hemorrhoids  or  piles  is  in  part  due  to  their 
dependent  position,  the  want  of  valves,  and  the  pressure  of  fecal 
masses,  etc.  They  may  also  be  symptomatic  of  pregnancy,  ovarian 
or  abdominal  tumors,  stricture  of  the  rectum,  prostatic  enlargement, 
etc.,  as  all  of  these  conditions  may  obstruct  the  return  of  venous 
blood.  These  veins  also  communicate  with  those  of  the  prostate  and 
bladder. 

Hemorrhoids  usually  commence  close  to  the  point  where  the  superior 
and  inferior  sets  of  veins  anastomose,  ./im<  vithin  the  anal  orifice,  where 
the  ano-redal  groove  is  produced  by  the  distension  of  the  internal  or 
superior  veins  above  it  and  the  external  or  inferior  veins  below  it. 
Both  sets  of  veins  are  usually  simultaneously  involved,  but  when  the 
internal  or  external  set  is  exclusively  or  predominantly  involved  the 
varicose  enlargement  is  called  an  internal  or  external  hemorrhoid  re- 
spectively. A  series  of  such  swellings  often  surrounds  the  outlet  of 
the  bowel.  Piles  are  usually  confined  to  the  submucous  or  subcuta- 
neous tissues  so  that  they  are  covered  only  by  the  niucoua  membrane 
(internal  piles)  or  skin  (external  piles).  The  mucous  membrane  or  the 
skin  on  the  surface  of  the  swelling,  due  to  the  dilated  and  sometimes 
thrombosed  veins,  is  chronically  inflamed.  The  mucous  meml)rane 
may  be  thickened,  thinned  or  ulcerated,  in  the  latter  case  leading  to 
"  blerdinr/  piles'' ;  the  skin  is  usually  thickened,  and  develops  into  a 
flabby  tab  when  acute  inflammation  is  absent. 

It  should  be  borne  in  mind  that  the  lower  rectum  thus  furnishes  an 
important  aiiasfomosi.'<  between  the  portal  and  caval  veins. 

The  nerve  supply  of  the  rectum  is  from  the  inferior  mesenteric  and 
hypogastric  sym})athetic  plexuses  and  the  sacral  plexus  (fourth  sacral 
nerve).  The  latter  accounts  for  the  paralysis  with  incontinence  of  feces 
that  follows  spinal  injuries  or  diseases  in  the  lumbar  region  or  above. 
It  is  also  mainly  responsible  for  the  close  nervous  association  between 
the  anus  and  the  outlet  of  the  bladder,  which  is  supplied  by  the  same 
nerve,  so  that  on  the  one  hand  painful  affections  of  the  former  may 
cause  a  frequent  desire  to  urinate  and  operations  on  the  anus  are 
especially  apt  to  be  followed  by  temporary  retention  of  urine ;  and  on 
the  other  hand  lesions  of  the  outlet  of  the  ijladder  are  often  associated 
with  tenesmus.  The  anus  is  supplied  by  the  internal  pudic  nerve,  which 
accounts  for  the  wide  distribution  of  reflex  pain  in  anal  fissure.  The 
uppjer  jjart  of  the  rectum  /.v  but  little  sensitive  as  illustrated  l)y  the  com- 
parative painlessness  of  new  growths  and  the  passage  of  instruments 
high  up  in  the  rectum.  On  the  other  hand  the  last  two  inches  of  the 
bowel  are  extremely  sensitive. 

The  lymphatics  of  the  rectum  enter  the  j>elvic  and  lumbar  nodes, 
those  of  tlie  anus  the  inguinal  nodes.  Thus  the  anus  has  a  blood, 
nerve  and  lymphatic  supply  independent  of  that  of  the  rectum. 


364  PELVIS  AND  PERINEUM. 

The  anus  is  an  oval,  not  a  circular,  orifice  at  the  lower  end  of  the 
anal  portion  of  the  rectum.  Hence  specula,  etc.,  should  be  introduced 
with  the  long  diameter  antero-posteriorly  in  the  long  axis  of  the  anus. 
The  anus  lies  in  the  median  line  \\  inches  in  front  of  the  coccyx,  mid- 
way between  the  two  ischial  tuberosities  and  only  slightly  further  from 
the  lower  border  of  the  symphysis  than  from  the  tuberosities.  In  health 
it  is  tightly  closed  and,  radiating  from  its  margins,  there  are  numer- 
ous puckerings  or  small  folds  of  skin,  between  which  fissures  or  ulcers 
of  the  anus  form  and  are  often  hidden.  The  painfulness  of  this  affec- 
tion is  due  to  the  reflex  contraction  of  the  sphincter,  compressing  the 
exposed  nerve  fibers  at  the  base  of  the  fissure  or  ulcer.  Hence  dilata- 
tion of  the  sphincter,  thereby  temporarily  paralyzing  it  and  tearing  tiie 
base  of  the  fissure,  gives  relief  and  affords  the  fissure  a  chance  to  heal. 
Incision  of  the  base  of  the  ulcer,  so  as  to  divide  part  of  the  sphincter, 
produces  a  similar  result.  The  anus  may  be  torn  by  large  hard  stools- 
during  defecation  and  some  such  tears  may  result  in  "  painful  fissure.'^ 

Near  the  anus  we  see  the  external  opening  in  cases  of  fistula  in  ano. 
The  most  common  form  is  the  result  of  marginal  abscesses,  superficial 
to  the  sphincters  and  lying  merely  beneath  the  skin  and  mucous  mem- 
brane. Their  internal  orifice  is  generally  found  a  little  above  the 
"white  line"  (mucocutaneous  junction)  just  within  the  grasp  of  the 
sphincter.  The  upicard  extension  of  an  ischiorectal  abscess  is  resisted 
by  the  levator  ani,  between  which  and  the  external  sphincter  it  finds  a 
point  of  least  resistance  to  extend  toward  the  rectum,  into  which  it 
opens  just  above  the  external  or  internal  sphincter.  The  abscess  be- 
fore opening  may  extensively  undermine  the  mucous  membrane,  so 
that  the  resulting  fistulous  tract  may  extend  upward  way  above  the 
internal  opening.  Tillaux  describes  a  form  of  fistula  which  may  ap- 
parently heal  but  again  breaks  out  on  the  same  or  the  opposite  side, 
and  which  he  attributes  to  a  hard  semilunar  valve-like  fold  at  the  upper 
end  of  the  rear  wall  of  the  anal  portion.  Division  of  this  stricture- 
like fold  results  in  a  cure  of  the  fistula,  whose  internal  opening  is  above 
the  level  of  this  fold. 

Inspection  of  the  anus  is  of  diagnostic  importance.  Thus  in  cases  of 
obstruction  due  to  stricture  of  the  rectum,  greatly  enlarged  prostate, 
etc.,  the  anus  is  patulous  and  flabby,  while  in  fissure  it  is  tightly  closed. 

Development  and  Errors  of  Development. — The  pelvic  portion  of 
the  rectum  h  formed  by  the  blind  caudal  end  of  the  hind  gut,  the  anal 
portion  by  an  invagination  of  the  surface  at  the  site  of  the  anus. 
Normally  the  sejitum  between  them  is  absorbed  so  as  to  form  a  continuous 
canal,  but  abnormally  it  may  leave  an  annular  constriction  an  inch  or 
so  within  the  anus  or  it  may  persist  and  form  an  imperforate  anus. 
In  such  cases  the  septum  persists  (1)  as  a  thin  membranous  scj)tum 
which  bulges  with  the  retained  meconium  and  may  be  readily  incised, 
or  (2)  as  a  thicker  partition  after  division  of  which  the  rectal  mucous 
membrane  must  be  brought  down  to  the  surface.  Again,  there  may  be 
no  anal  pouch  whatever,  and  in  such  cases  the  lower  end  of  the  rectal 
portion  may  or  may  not  be  deficient.     In  infants  with  obstinate  con- 


SHAPE  AND  POSITION   OF   THE  BLADDER.  365 

stipation  digital  examination  of"  tlie  rectum  must  not  be  neglected.  If 
a  careful  dissection  through  a  median  incision  prolonged  l)ack  to  the 
coccyx  and  carried  up  to  the  front  of  tlie  coccyx  and  sacrum  fails  to 
discover  the  rectal  pouch  an  inguinal  colostomy  must  be  made. 

Ill  rare  cases  the  recfiiin  ojjcns  cutaneously  af  sdihc  unusual  polid 
(symphysis,  prepuce,  perineum,  sacral,  gluteal  or  lumbar  regions)  and 
usually  by  a  long  canal  with  a  narrow  aperture.  More  often  it  opens 
into  the  genito-urinary  tract,  bladder,  urethra,  or  vagina.  Primarily 
the  allantoic  vesicle,  from  which  tlie  bladder  and  tlie  posterior  urethra 
are  formed,  was  derived  from  and  ojiened  into  the  hind  gut.  The  per- 
sistence of  this  connection  may  explain  the  rare  opening  between  the 
rectum  and  the  bladder.  The  rectal  pouch  in  such  cases  lies  so  high 
up  that  inguinal  colostomy  must  be  resorted  to.  The  opening  into 
the  bladder  or  urethra  is  usually  small  and  requires  operative  relief  if 
possible.  I  have  seen  the  opening  into  the  vagina  sufficient  for  the 
purposes  of  defecation,  and  this  condition  has  been  often  reported.  In 
the  latter  case  operation  should  be  deferred  until  after  puberty,  when 
the  increased  size  of  the  pelvis  and  perineum  facilitates  a  plastic  oper- 
ation. Women  have  even  married  and  borne  children  with  a  vaginal 
outlet  to  the  rectum  and  without  inconvenience  from  the  latter. 

In  operations  for  the  removal  of  neoplasms  or  for  resection  of  stric- 
tures of  the  rectum  room  may  be  gained  and  the  exposure  of  the  parts 
increased  by  excising  the  coccyx,  after  incising  back  to  the  sacrum. 
Or,  following  Kraske's  method  or  one  of  its  modifications,  the  lower 
end  of  the  left  half  or  both  halves  of  the  sacrum  may  be  permanently 
or  temporarily  resected  (osteoplastic  method).  In  these  operations  the 
lower  border  of  the  third  sacral  foramen  should  be  the  upper  limit  of 
the  resection  of  bone,  for  if  it  is  carried  higher  there  is  a  risk  of  perma- 
nent paralysis  of  the  bladder  from  interference  with  the  third  sacral 
nerves.  These  operations  are  carried  out  on  the  left  side,  for  it  is  on 
that  side  that  the  lower  or  pelvic  portion  of  the  sigmoid  loop  lies.  By 
division  of  the  sacro-sciatic  ligaments  or  resection  of  their  sacral  attach- 
ments the  entire  sacro-iliac  notch  is  opened  up.  When  possil)le  it  is 
advisable  to  save  the  anal  portion,  containing  the  sphincters,  and  use  it 
by  suturing  the  upper  segment  to  it. 

The  Bladder. 

The  shape,  position  and  relations  of  the  bladder,  or  urinary  reser- 
voir, depend  upon  age,  sex,  and  the  degree  of  distension  of  the  organ. 
The  average  capacity  is  about  a  pint  (400  to  oCtOc.c.)  but  may  reach 
1,000  c.c.  under  normal  conditions,  ^^'hen  distended,  in  cases  of  re- 
tention, etc.,  the  bladder  has  held  as  much  as  ,S,()00  to  4,000  c.c.  of 
urine,  and  Tillaux  reports  a  case  in  which  it  held  7  liters  (7,000  c.c). 
On  the  other  hand  a  contracted  bladder  may  contain  no  more  than  10 
to  20  c.c.  The  bladder  of  the  male  is  somewhat  more  capacious  than 
that  of  the  frinalc. 

Shape  and  position  of  llu'  adult  male  bladder.  The  form  of  the  empty 
bladder  is  a  disputed  point.     Two  forms  are  described:  (1)  the  »i/stollc 


366  PELVIS  AND  PERINEUM. 

or  contracted  form,  in  which  the  bladder  represents  a  firm  oval  whose 
cavity,  on  sagittal  section,  forms  with  that  of  the  urethra,  a  continuous 
curved  slit,  and  (2)  the  diastolic  or  relaxed  form,  in  which  the  upper 
aspect  presents  to  the  intestines  a  cup-shaped  concavity  and  the  cavity, 
with  that  of  the  urethra,  presents  a  Y-shaped  fissure  on  sagittal  section. 
It  is  probable  that  the  systolic  form  is  the  common  one  during  life. 

When  moderately  filled  it  is  entirely  within  the  pelvic  cavity  and  has 
a  rounded  form,  which  may  be  flattened  or  transversely  elongated  by 
the  pressure  of  the  adjoining  viscera.  ^,s  it  becomes  distended  it  be- 
comes oval,  the  convexity  of  the  superior  and  postero-inferior  surfaces 
is  increased,  the  anterior  surface  is  flattened  and  its  upper  part,  rising 
out  of  the  pelvis,  is  in  contact  with  the  back  of  the  anterior  belly  wall. 
This  fact  is  taken  advantage  of  in  suprapubic  cystotomy  and  tapping. 
In  distension  the  upper  or  smaller  end  comes  more  and  more  in  contact 
with  the  anterior  belly  wall  and  may  reach  the  umbilicus  and  even,  it 
is  said  (Tillaux),  the  diaphragm.  The  distended  bladder  is  not  quite 
symmetrical  but  deviates  slightly  to  the  right,  owing  partly  to  the 
rectum  on  the  left  side  and  partly  to  the  greater  size  of  the  right  half 
of  the  bladder.  When  distended  so  that  its  upper  end  is  at  the  upper 
margin  of  the  symphysis,  its  long  axis  is  directed  from  the  latter  point 
to  the  end  of  the  coccyx. 

The  vesical  outlet  (or  internal  urinary  meatus)  is  on  a  horizontal 
line  a  little  below  the  center  of  the  symphysis,  about  an  inch  behind 
the  latter  and  2  to  1^  inches  above  the  perineum.  In  distension  the 
bladder  is  displaced  dotvnward  as  well  as  upward,  displacing  the  peri- 
neum so  that  its  outlet  is  at  a  somewhat  lower  level,  while  in  cases  of 
prostatic  enlargement  the  outlet  may  be  displaced  upward,  even  above 
the  symphysis. 

The  bladder  lies  behind  the  anterior  pelvic  wall,  in  front  of  and 
above  the  rectum  in  the  male,  the  cervix  uteri  and  the  upper  end  of 
the  vagina  intervening  in  the  female,  and  in  contact  with  the  small 
intestines  and  the  sigmoid  loop  above  and  behind. 

Relations  to  the  Peritoneum.  (Figs.  85  and  87.) — The  peritoneum 
covers  the  entire  superior  surface,  the  lateral  surfaces  down  to  the  line 
of  the  obliterated  hypogastric  artery,  or  a  line  extending  from  the 
urachus  to  a  point  somewhat  below  the  summit  of  the  seminal  vesi- 
cles, and  the  upper  part  of  the  posterior  surface,  to  the  bottom  of  the 
rectovesical  pouch.  This  pouch  is  usually  filled  with  convolutions  of 
the  small  intestine,  separating  the  bladder  and  rectum,  and  it  reaches 
to  a  point  just  below  the  upper  ends  of  the  seminal  vesicles  and  about 
an  inch  above  the  ])rostate  (three  inches  from  the  anus).  It  forms  the 
upper  limit  of  the  triangular  area  over  which  the  rectum  and  bladder 
are  closely  adherent. 

Normally  the  peritoneum  lines  the  anterior  abdominal  wall  down  to 
the  symphysis  pubis,  from  which  it  passes  onto  the  upper  end  and 
superior  surface  of  the  bladder.  As  the  distended  bladder  rises  above 
the  pelvis  it  pushes  up  this  parietal  peritoneum  which  thus  comes  to 
cover  the  upper  half  of  that  part  of  the  anterior  bladder  surface  which 


ENTRANCE  OF  THE   URETERS.  367 

extends  above  the  symphysis,  while  the  lower  half  of  this  surface  is  in 
direct  contact  with  the  anterior  belly  wall,  just  above  the  symphysis, 
without  the  intervention  of  the  peritoneum.  It  is  this  arrangement 
of  the  peritoneum  tiiat  renders  suprapubic  cystotomy  or  tapping  a 
feasible  and  safe  operation,  for  we  can  thus  puncture  or  open  a  dis- 
tended bladder  above  the  symphysis  without  opening  the  i)eritoneum. 
Exceptionally  the  peritoneum  is  adherent  to  the  pubes  so  that  it  can- 
not be  pushed  up  by  the  bladder.  In  operating  on  suchla  case 
wounding  of  the  peritoneum  would  be  likely,  but  this  wound  could  be 
sutured,  the  ])critoneum  carefully  detached  below  and  drawn  upward, 
and  the  bladder  then  opened. 

Theoretically  the  lower  half  of  that  part  of  the  anterior  bladder  sui-- 
face  above  the  symphysis  should  be  devoid  of  peritoneum  no  matter 
how  high  the  bladder  rises,  but  ])ractically  there  is  seldom  more  than  2 
or  2^  inches  between  the  symphysis  and  the  peritoneum,  though  the  lat- 
ter can  be  retracted  still  further  upwards.  When  the  l)ladder  reaches 
half  way  from  the  symphysis  to  the  umbilicus  there  will  be  this  2  or  2^ 
inches  of  the  anterior  abdominal  wall  above  the  symphysis  devoid  of 
peritoneum  and  in  direct  contact  with  the  anterior  bladder  Avail.  The 
use  of  Petersen's  rubber  bag,  inflated  in  the  rectum,  prevents  the  bladder, 
filled  with  8  ounces  of  fluid,  from  extending  downward  and  backward 
toward  the  perineum,  and  at  the  same  time  directly  raises  it  and  thus 
helps  to  bring  it  in  contact  with  the  anterior  belly  wall,  but  it  has  no 
special  influence  in  raising  the  peritoneal  fold  above  the  symphysis. 
By  the  use  of  Trendelenburg's  position  gravity  tends  to  bring  the  mod- 
erately filled  bladder  above  the  symphysis  pubis  and  in  contact  with 
the  anterior  abdominal  wall,  so  that  I  have  discarded  the  rectal  bag  as 
unnecessary.  In  fact  I  have  found  little  difficulty  in  opening  the 
empty  bladder,  supra  pubes,  by  the  use  of  the  Trendelenburg  position. 

The  anterior  surface  and  that  part  of  the  lateral  surfacc\s  below  the 
limit  of  the  peritoneum  is  separated  from  the  obturator  and  levator  ani 
muscles,  of  the  anterior  and  lateral  pelvic  walls,  by  a  quantity  of  loose 
areolar  tissue  whose  meshes  contain  much  fat.  This  tissue  ensheaths 
the  vesical  vessels  and  occupies  an  area  ( cavum  Retzii )  more  or  less 
triangular,  with  its  base  directed  downward,  and  shut  in  by  the  peri- 
toneum above.  The  l()ose)icss  of  t/iis  tissue  readily  allows  changes 
in  dimension  without  disturbing  the  connections  of  the  bladiler,  and 
it  also  favors  the  rapid  and  wide  spread  of  inflammation  following 
wounds  of  the  bladder  with  extravasation  of  urine.  This  tissue 
separates  the  distended  bladder  from  the  anterior  abdominal  wall, 
below  the  fold  of  the  peritoneum.  Ilence  it  is  opened  up  in  supra- 
pubic cystotomy  and  traversed  by  a  trocar  in  tapping  the  bladder  so 
that  suppuration  in  this  tissue,  and  iu  rare  cases  death,  has  followed 
the  latter  procedure.  This  tissue  is  also  r()nti)iuous  above  and  at  the 
sides,  vifli  the  abdominal  and  pelvic  subj)erit())ieal  eonnerlire  tissue, 
luMiee  an  iullaniination  in  it  may  become  widely  diffused. 

The  ureters  pierce  the  bladder  (Fig.  S7)  at  the  juuetion  of  the  lat- 
eral and  posterior  surfaces,   about  IJ  inches  from  each   other  and  the 


368  PELVIS  AND   PERINEUM. 

same  distance  above  the  prostate  ;  just  above  the  outer  and  upper 
limits  of  the  triangular  area  of  vesicorectal  contact ;  near  to,  though 
not  in  contact  with,  the  rectum,  so  that  a  calculus  in  the  lower  end  of 
the  ureter  may  possibly  be  palpated  through  the  rectum.  The  vasa 
deferentia  c/'o.s.s  the  later nl  bladder  irall  from  before  backward  and  above 
downward  to  reach  the  inner  side  of  the  seminal  vesicles  and  form  the 
sides  of  the  above-mentioned  triangular  area  on  the  posterior  vesical  sur- 
face. They  cross  the  obliterated  hi/pogastric  arteries,  and  thence  to  the 
above  triangular  area  they  lie  subperitoneally.  They  pass  between  the 
bladder  and  the  ureters  just  where  the  latter  pierce  the  bladder. 

Rupture  of  the  bladder  is  more  serious  when  it  involves  in 
whole  or  in  part  the  portion  covered  by  peritoneum.  A'^iolence  applied 
to  the  anterior  belly  wall  may  rupture  the  distended  bladder  without 
fracture  of  the  pelvis  or  any  external  sign  of  injury.  The  bladder 
may  be  torn  by  bony  fragments  of  a  fractured  pelvis  or,  rarely,  in 
case  of  an  injury  of  the  rectum  or  vagina.  When  the  bladder  is  dis- 
tended by  urine,  in  neglected  cases  of  stricture,  the  urethra  gives  way 
as  a  rule  before  the  bladder  and  the  urine  is  extravasated  into  the 
perineum.  But  rupture  of  the  viscus  has  resulted  in  some  cases  from 
congenital  closure  of  the  urethra  in  infants  and  in  neglected  cases  of  re- 
tention of  urine,  especially  in  women.  When  the  bladder  is  artificially 
over-distended  it  usually  gives  way  laterally,  below  the  peritoneal 
reflection  (Tillaux),  but  most  ruptures  intra  vitam  involve  in  part,  at 
least,  the  surface  covered  by  peritoneum,  for  it  is  this  part  that  is  most 
distended  when  the  bladder  is  filled.  In  intraperitoneal  ruptures  urine 
is  extravasated  into  the  peritoneal  cavity  which  it  does  not  irritate  if 
normal  and  fresh,  but  when  abnormal  or  after  becoming  stagnant. 
Hence  a  primary  condition  of  treatment  is  the  free  drainage  of  the 
bladder  and  hence  also  the  fatality  of  such  ruptures  unless  the  rent  is 
repaired  by  suture  and  the  extravasated  urine  is  removed  from  the 
peritoneal  cavity.  The  injury  is  indicated  by  inability  to  urinate, 
the  urine  passing  through  the  rent  into  the  peritoneal  cavity,  by  the 
catheter  removing  only  a  little  blood-stained  urine,  and  by  only  a 
part  of  the  fluid  injected  returning  by  the  catheter.  If  the  rupture 
is  extraperitoneal  the  urine  escapes  into  the  loose  cellular  tissue  of  the 
cavum  Retzii  and  cellulitis  and  abscess  results,  though  recovery  often 
ensues.  Stab  or  bullet  wounds  take  the  same  course  according  as  they 
are  intra-  or  extraperitoneal,  except  that  a  small  bullet  wound,  like 
the  puncture  of  a  small  trocar,  may  become  at  once  plugged  by  the 
mucous  membrane  and  the  muscular  contraction  of  the  wall,  thus  pre- 
venting extravasation. 

Fixation  of  the  Bladder. — The  reflections  of  peritoneum  onto  the 
bladder,  known  as  its  false  lir/aments,  steady  it  without  fixing  it,  while 
the  bands  of  thickened  rectovesical  fascia,  reflected  onto  its  base  and 
known  as  its  true  ligaments,  anchor  this  part.  It  is  still  further  fixed 
in  position  by  its  attachment  behind  to  the  rectum  in  the  male  and  the 
uterus  and  vagina  in  the  female,  and  by  the  connection  of  the  ureters, 
urethra,  prostate  and  the  fibro-muscular  cord  of  the  urachus. 


THE  BLADDER    WALL.  309 

Malposition. — In  spite  of  these  various  nieans  of  anchoring  the 
bladder  it  lias  h^t^n  found  in  inj^uinal,  femoral,  vaginal  and  other  forms 
of  pelvic  hernke.  In  inguinal  and  femoral  hernia,'  tiie  j)art  herniated 
may  be  entirely  extraperitoneal,  or  in  part  intraperitoneal.  An  al>nor- 
mally  high  position  of  the  bladder  may  be  due  to  prostatic,  rectal  or 
pelvic  tumors. 

The  bladder  wall  varies  in  thick hc.sh  from  one  eightii  inch,  when 
moderately  distended,  to  one  half  inch  or  more  when  contracted.  The 
anterior  wall  and  trigone  are  somewhat  thicker  than  the  rest  of  the 
bladder.  When  there  is  obstruction  to  the  escape  of  urine  the  hhidder 
muscle  lu/pertrophics  from  undue  exercise,  like  other  muscles.  In  such 
cases  the  interlacing  network  of  the  internal  layer  of  fibers  is  thickened 
and  appears  as  distinct  intersecting  ridges  beneath  the  mucous  mem- 
brane (the  fasciculated  bladder).  The  bladder  wall  in  the  interspaces  of 
this  network  is  thinner  and  weaker,  and  its  mucous  memi)rane  may 
become  protruded  or  lierniated  in  the  form  of  sacculi,  by  the  increased 
intravesical  pressure  {the  sacculated  bladder).  One  or  several  of  these 
sacculi  may  become  so  enlarged  as  to  allow  urine  to  stagnate  and  decom- 
pose, phosphatic  deposits  to  form  and  collect,  and  calculi  to  developer 
become  hidden  [encysted  calculi).  "When  a  calculus,  previously  con- 
tained in  the  bladder,  slips  into  a  sacculus  the  symptoms  suddenly 
subside  and  the  stone  can  no  longer  be  felt  by  the  searcher.  Digital 
rectal  examination  may  sometimes  reveal  the  presence  of  such  calculi. 
The  ridges  of  a  fasciculated  bladder  may  become  encrusted  with  phos- 
phatic deposits  and  give  rise  to  possible  errors  in  diagnosis  in  the 
use  of  the  searcher.  When  only  one  sacculus  is  developed  it  may 
become  enlarged,  even  to  the  size  of  the  bladder,  and  give  rise  to  the 
erroneous  designation  "  double  bladder.''^  Below  and  in  front  the  longi- 
tudinal fibers  of  the  external  lat/er,  known  from  its  action  as  the  defru.'<or 
unnce  muscle,  pass  on  each  side  in  front  of  the  prostate  to  the  back  of  the 
pubic  bones  as  the  vesicopubic  muscle,  while  superiorly  the  longitudinal 
fibers  are  continued  into  the  urachus.  The  circular  fibers  (f  the  middle 
layer  are  aggregated  near  the  vesical  outlet  where  they  are  known  as  the 
iyiternal  sphincter  of  the  bladder,  though  llenle  has  shown  that  their 
action  is  to  empty  the  bladder  of  the  last  drops  of  urine,  the  real  inter- 
nal sphincter  being  the  circular  fibers  of  the  upper  prostatic  urethra. 

The  entire  bladder  is  invested  by  the  rectovesical  ftscia  which  is  much 
thicker  at  its  lower  part.  The  ela.stic  submucous  layer  is  intimately 
connected  with  the  mucous  membrane  which  it  loosely  connects  with 
the  muscular  layers,  except  over  the  trigone,  where  the  two  are  closely 
adherent,  a  fact  of  importance,  for  otherwise  the  trigonal  mucous  mem- 
brane would  be  prolapsed  into  and  block  uj)  the  urethral  orifice  during 
micturition.  As  a  result  of  this  adhesion  the  mucous  membrane  of  the 
trigone  is  always  smooth,  while  that  of  the  rest  of  the  bladder  is 
thrown  into  rugie  when  the  bladder  is  empty.  The  laxity  of  the  mu- 
cous membrane  allows  of  the  great  changes  of  size  of  the  viscus.  The 
mucous  membrane  is  rose  colored,  but  over  the  trigone  it  is  somewhat 
paler. 
24 


370  PELVIS  AND  PERINEUM. 

Blood  and  Nerve  Supply. — The  blood,  derived  from  the  three  ves- 
ical arteries  and  small  twigs  from  the  arteries  of  the  neighboring  parts 
(uterine  and  vaginal  in  the  female),  is  returned  by  the  veins  into  the 
internal  iliac  vein.  When  inflamed  the  mucous  membrane  is  deeply 
injected  and  bleeds  readily.  The  veins  form  plexuses  around  the  lower 
end  or  base  of  the  bladder,  which  are  connected  with  those  of  adjacent 
parts,  especially  with  those  of  the  prostate  in  the  male,  forming  the  vesi- 
coprostatic  plexus.  Hence  in  enlargement  of  the  prostate  this  plexus 
becomes  varicose  (vesical  hemorrhoids),  from  the  pressure  of  the  enlarge- 
ment upon  it.  In  such  cases  the  varicose  veins  project  into  the  bladder 
near  its  outlet  where  they  are  liable  to  bleed  spontaneously  or  from  the 
use  of  instruments  and,  by  producing  a  swelling  and  congestion  of  the 
raucous  membrane  here,  they  cause  frequent  niicturition.  The  bleeding 
may  temporarily  relieve  the  congestion  and  the  symptoms  caused 
thereby.      Bleeding  from  the  bladder  usually  indicates  tumor  or  stone. 

The  lymphatics  of  the  bladder  are  not  numerous,  except  perhaps 
near  the  outlet,  and  their  existence  even  has  been  denied  by  Sappey. 
They  empty  into  the  internal  iliac  nodes.  Resorption  from  the  blad- 
der contents  probably  does  not  occur  when  the  mucous  membrane  is 
intact,  but  only  a  slight  diffusion. 

The  nerves  are  derived  from  the  hypogastric  plexus,  supplying  the 
mucosa,  and  the  third  and  fourth  sacral  nerves  suppjlying  the  muscularis. 
The  mucosa  of  the  greater  part  of  the  bladder  is  only  slightly  sensi- 
tive, as  may  be  observed  in  the  passage  of  a  sound  or  searcher,  that  of 
the  trigone  and  the  neighborhood  of  the  outlet  is  much  more  sensitive. 
When  the  bladder  is  inflamed  its  mucosa,  especially  that  near  the  out- 
let, is  much  more  sensitive,  as  seen  in  cases  of  cystitis  or  in  stone.  In 
the  upright  position  the  stone  gravitates  to  the  highly  sensitive  trigone, 
and  in  micturition  it  is  forced  against  the  outlet,  causing  great  pain 
and  perhaps  suddenly  checking  the  flow  of  urine.  Sudden  distension 
of  the  bladder  causes  acute  pain,  but  it  may  become  gradually  distended 
with  only  a  sense  of  discomfort. 

When  the  nerves  supplying  the  bladder  are  paralyzed  from  injury  or 
disease  of  the  cord,  distension  ensues  from  lack  of  power  to  empty  it, 
and  the  consciousness  of  the  bladder  being  distended  is  lost.  Thus  we 
have  retention  of  urine,  but  in  time  the  outlet  is  opened  up  by  the 
pressure  and  overflow  or  incontinence  of  urine  occurs,  the  bladder  re- 
maining distended.  In  the  child  incontinence  (usually  nocturnal) 
generally  occurs  from  irritability,  not  from  distension.  Retention  may 
also  occur  from  obstruction  due  to  stricture,  enlarged  prostate,  etc.,  but 
however  it  occurs,  long-continued  over-distension  produces  temporary 
paralysis  by  stretching  the  muscular  fibers.  Thus  the  urine  flows  from 
the  catheter  without  force  and  catheterization  must  be  continued  for 
some  time.  The  sudden  complete  evacuation  of  all  the  urine  in  an 
over-distended  bladder,  by  removing  the  pressure  on  its  blood  vessels, 
causes  such  a  relaxation  and  over-filling  of  them  that  oozing  of  blood 
occurs  into  the  bladder.  Hence  the  advice  not  to  completely  empty  at 
once  an  over-distended  bladder.     In  cases  of  repeated  or  long-continued 


THE  ISTERIOR   OF  THE  BLADDER. 


371 


over-distension  the  ureters  become  d'uttended,  even  to  tlie  size  of  the  small 
intestine,  not  by  a  reflux  from  the  bladder,  for  the  greater  the  pressure 
within  the  bladder  the  more  tightly  are  their  orifices  closed,  but  by  an 
accumulation  within  the  ureters  which  cannot  enter  the  bladder. 


Fio.  86. 


BUNDLES    OF 

TUDINAL    M 

FIBRES     F 

URETE 


OPENIN 
UBET 


URETHRAL 
ORIFICE 


Trigone  of  the  bladder  with  a  flap  of  mucosa  dissected  up  from  the  greater  part  of  it,  showing 
the  mode  of  termination  of  the  ureter  and  the  prolongation  or  the  bundles  of  its  longitudinal  muscle 
fibers  along  the  boundaries  ol  the  trigone.    A  grooved  director  leads  to  post-trigonal  pouch.  (Testx'T.) 

The  interior  of  the  bladder  presents  three  orifices,  the  outlet  or 
intenud  urinary  meatu.s,  at  the  most  dependent  part  of  the  bladder  in 
the  erect  position  and  at  the  apex  of  an  equilateral  triangle,  the  trigone, 
whose  two  other  angles  are  formed  by  the  orifice-'<  of  the  tiro  ureters, 
each  one  inch  (18  to  25  mm.)  from  the  outlet.  Connecting  the  two 
ureteral  orifices  and  bounding  the  base  of  the  trigone  is  an  arched 
elevation  (plica  ureterica),  due  to  a  band  of  muscle  fibers  continued 
from  the  ureters.  In  chronic  cases  of  obstruction,  as  in  cases  due  to 
prostatic  hypertrophy,  this  ridge  forms  the  anterior  boundary  of  the 
depression  known  as  the  post  prostatic  pouch  (/o.s.sa  rctrourcierica).  The 
longitudinal  mesial  ridge  of  mucous  membrane,  the  ^lvula  vesiccv  (or 
uvula  of  Lieiitaiid),  passes  from  the  middle  of  the  above  ridge  to  near 
the  outlet,  where  it  is  most  prominent.  It  is  especially  marked  in 
old  age  and  corresponds  to  the  middle  portion  of  the  prostate. 

The  ureters,  reaching  the  bladder  1},  inches  apart,  pass  so  obliquely 
through  its  wall  for  half  an  inch  that  their  oblique  passage  serves  the 
purpose  of  a  valve,  preventing  reflux  from  the  bladder  and  acting  more 
perfectly  the  fuller  the  bladder,  lender  pathological  conditions  the 
valvular  action  may  be  imperfect,  allowing  l)ackward  flow,  and  Lewin's 
experiments  on  rabbits  would  indicate  that  the  same  may  occur  under 
normal  conditions  when  the  bladder  is  not  too  full. 


372  PELVIS  AND  PERINEUM. 

The  female  bladder  has  its  longest  diameter  transversely  owing  to  the 
greater  width  of  the  female  peivis  and  the  presence  of  the  uterus  and 
vagina  behind  it.  Owing  to  the  less  depth  of  the  symphysis  the  out- 
let is  relatively  loiver,  i.  e.,  horizontally  behind  the  lower  end  of  the 
symphysis ;  and,  there  being  no  prostate,  it  is  a  trifle  nearer  the  sym- 
physis and  very  distensible.  This  distensibility  of  the  outlet,  in  con- 
nection with  the  shortness  and  dilatability  of  the  urethra,  enables  us 
to  explore  the  female  bladder  with  the  finger,  to  remove  stones  and 
foreign  bodies  through  the  urethra,  and  to  more  readily  examine  the 
interior  of  the  bladder  with  the  cystoscope.  For  the  same  reason  stone 
and  cystitis  are  less  common  and  foreign  bodies,  introduced  per 
urethram,  more  common  than  in  the  male.  The  peritoneum  does  not 
descend  so  low  on  the  posterior  surface  in  the  uterovesical  pouch,  which 
separates  the  bladder  from  the  body  of  the  uterus,  as  in  the  male  in 
the  rectovesical  pouch.  Below  this  pouch  the  bladder  is  in  contact  with 
the  cervix  uteri  and  the  upper  half  of  the  vagina.  A  slight  continua- 
tion of  the  subperitoneal  connective  tissue  extends  between  the  bladder 
and  the  cervix,  thus  facilitating  their  separation  in  removal  of  the  cer- 
vix or  uterus,  if  the  operator  follows  this  tissue  layer.  The  close  relation 
of  the  bladder  and  the  vagina  explains  the  frequency  of  vesicovaginal  Jis- 
tuke,  which  are  apt  to  follow  a  tear  or  sloughing  of  the  anterior  vaginal 
wall,  the  result  of  difficult  labor.  The  ureteral  orifice  is  3  cm.  below 
the  cervix  uteri  and  opposite  the  middle  of  the  vagina,  hence  calculi 
can  be  felt  per  vaginara  in  the  lower  ends  of  the  ureters,  which  are 
also  in  danger  of  being  injured  in  operations  on  the  cervix. 

The  bladder  in  the  infant  is  pear-shaped,  with  the  small  end  above 
and  in  front  at  the  urachus,  which  represents  the  stalk  of  the  pear. 
At  birth  the  outlet  is  behind  the  upper  margin  of  the  symphysis  and 
the  bladder  is  largely  in  the  abdomen  and  entirely  above  the  level  of  the 
symphysis,  only  about  one  half  of  the  organ  being  below  the  pelvic  brim, 
as  the  pelvis  is  small  and  occupied  mainly  by  the  rectum.  Hence  in 
perineal  lithotomy  in  young  children  the  knife  must  be  directed  well 
upward  to  reach  the  bladder.  The  position  and  relations  of  the  blad- 
der begin  to  change  when  the  child  commences  to  walk  and  are  about 
like  those  of  the  adult  by  the  age  of  six.  Before  this  condition  is 
reached  the  anterior  loall  of  the  bladder,  uncovered  by  peritoneum,  is 
in  contact  with  the  anterior  abdominal  wall  and  readily  accessible  to 
suprapubic  operations  or  puncture.  In  young  male  children  the  recto- 
vesical fold  extends  nearly  or  quite  to  the  base  of  the  very  small  pros- 
tate, which  brings  it  very  close  to  the  vesical  outlet,  in  fact  at  birth  it 
reaches  this  level.  The  bladder  wall  is  so  thin  that  it  is  said  that  a 
"  click  "  may  be  elicited  through  this  wall  from  the  pelvic  bones  in 
sounding  for  stones. 

Formation. — The  bladder,  female  urethra  and  the  prostatic  and 
membranous  parts  of  the  male  urethra  are  formed  by  that  portion 
of  the  allantoic  vcmcIc  which  lies  within  the  body  cavity  and  ex- 
tends between  the  hind  gut  and  the  umbilicus.  The  ujjper  part  of 
this  is  normally  obliterated  to  form  the  urachus,  the  lower  part  is  par- 


THE  PROSTATE.  373 

titioned  off  from  the  cloaca,  or  common  opening  of  the  urinary  and 
alimentary  tracts,  by  the  growth  of  a  partition  which  forms  the  peri- 
neum. 

Malformations. — Faulty  growth  of  this  partition  may  lead  to  fis- 
tulse  between  the  rectum  and  bladder  or  urethra,  luirophy,  or  con- 
genital hiatus  of  the  bladder,  and  patency  of  the  urdc/ius  have  been 
referred  to  under  Anterior  Abdominal  AValls  (pp.  252  and  259j,  recto- 
vesical fistula  under  Rectum  (p.  305).  These  are  congenital  conditions, 
dcjK'uding  upon  errors  of  development. 

New  growths  of  the  bladder  include  epithelioma,  fibroma,  myoma 
and,  in  early  life,  sarcoma.  They  are  especially  apt  to  take  on  a 
villous  form  and  to  involve,  like  other  pathological  processes,  the 
lower  part  of  the  bladder,  where  they  may  occasionally  ol)struct  the 
outlet  and  bleed  freely.  The  contents  of  the  posterior  urethra  can 
pass  readily  into  the  bladder,  those  of  the  anterior  urethra  only  by 
injection  under  high  pressure.  The  bladder  may  he  reacJied  and  opened 
for  exploration,  drainage,  or  the  removal  of  stone,  foreign  bodies,  tumors, 
etc.,  by  two  routes:  (1)  pe)nneal{see  Perineum);  (2)  suprapubic  (see  pp. 
254  and  367). 

The  Prostate. 

The  prostate  (Figs.  85,  87,  93,  94  and  95)  is  an  elastic,  contractile 
organ  of  the  nude  (jenerative  syntein  which  embraces  the  vesical  outlet 
and  encloses  the  first  (prostatic)  portion  of  the  urethra.  That  it  be- 
longs to  the  generative  rather  than  the  urinary  organs  is  shown  by  its 
small  size  during  childhood,  its  sudden  growth  at  puberty  (together 
with  the  testicles,  etc.),  its  atrophy  or  small  size  after  castration  and 
in  eunuchs,  and  its  anatomical  relations  with  the  ejaculatory  ducts  and 
the  prostatic  utricle.  These  facts  led  to  the  suggestion,  by  J.  William 
White,  of  castration  for  prostatic  hypertrophy. 

In  size  and  shape  the  adult  prostate  is  not  unlike  a  horse  chestnut, 
measuring  1^  inches  from  base  to  apex,  1^  inches  transversely  and 
1  inch  from  before  backward,  and  weighing  6  drachms.  AVhen  the 
gland  is  appreciably  larger  (according  to  Sir  H.  Thompson,  when  it 
weighs  one  ounce  and  measures  two  inches  transversely)  hypertrophy 
or  enlargement  of  the  prostate  is  said  to  exist.  This  may  occur  occa- 
sionally at  an  earlier  age  but  is  so  common  after  the  age  of  fifty-five  that 
it  is  estimated  to  occur  in  34  per  cent,  of  men  over  sixty.     (Thompson.) 

The  anatomical  effects  of  enlargement  are  to  lengthen  and  compress 
the  prostatic  urethra,  to  increase  its  curvature  in  many  cases  and 
sometimes  to  produce  a  lateral  curvature  (due  to  the  greater  enlarge- 
ment of  one  side),  and  to  cause  the  gland  to  project  in  the  directions 
of  least  resistance,  backward  into  the  rectum  and  upward  into  the 
bladder,  so  as  to  raise  the  outlet  ai)ov('  the  most  dependent  part  of  the 
bladder  and  lead  to  the  formation  of  the  postprostatic  |K)Uch.  The 
physiological  effects  are  :  (1)  increased  difficulty  of  micturition,  due  to 
compression  of  the  urethra  and  obstruction  of  the  vesical  outlet  by  a 
prominent  middle  portion  and  by  raising  the  outlet,  and  (2)  increased 
fre<inency  of  micturition,  due  to  congestion   of  the   U)wer  end   of  the 


374  PELVIS  AND  PERINEUM. 

bladder  from  the  pressure  of  the  enlargement  on  the  vesicoprostatic 
plexus. 

As  a  rule  the  enlargement  implicates  the  prostate  pretty  uniformly. 
If  the  lateral  lobes  are  chiefly  involved  the  gland  may  attain  consider- 
able size  without  causing  serious  symptoms,  whereas  a  trifling  enlarge- 
ment of  the  middle  portion  or  of  the  glandular  portion  beneath  the 
floor  of  the  vesical  outlet  may  cause  marked  obstruction.  Occasionally 
a  pedunculated  median  growth  projects  into  the  bladder  and  obstructs 
the  outlet  like  a  ball  valve. 

We  can  clearly  distinguish  two  lateral  lobes  of  the  prostate,  espe- 
cially when  we  look  at  the  posterior  surface  where  they  are  separated 
by  a  shallow  furrow.  This  widens  out  above  into  a  wedge-shaped 
furrow,  which  is  continuous  with  a  transverse  furrow  on  the  base,  in 
which  the  ejaculatory  ducts  enter  the  prostate.  Between  this  latter 
furrow  and  the  course  of  the  ejaculatory  ducts  behind,  the  urethra  in 
front  and  the  diverging  upper  ends  of  the  lateral  lobes  on  the  sides, 
lies  the  "  middle  portion  "  or  so-called  "  middle  lobe."  When  normal 
it  is  scarcely  an  anatomical  entity  but  in  some  cases  of  prostatic  en- 
largement this  part  may  be  principally  or  exclusively  enlarged.  In 
such  cases,  as  it  corresponds  to  the  uvula  vesicae,  it  projects  into  and 
obstructs  the  vesical  outlet,  occasionally  as  a  pedunculated  tumor. 
The  base  of  the  prostate,  surrounding  the  vesical  outlet,  receives  the 
latter  in  a  funnel-shaped  depression  somewhat  in  front  of  its  middle. 
The  prostatic  urethra  traverses  the  gland  from  base  to  apex  a  little  in 
front  of  its  middle,  rarely  it  merely  grooves  the  anterior  surface  or,  in 
other  cases,  passes  more  posteriorly. 

The  position  of  the  prostate  is  such  that  its  axis  from  base  to  apex 
is  nearly  vertical  in  the  erect  position.  The  apex,  resting  upon  the 
deep  layer  of  the  triangular  ligament,  lies  J  to  f  inch  behind,  and  a 
little  below  the  symphysis,  and  1:^  to  1|  inches  from  the  margin  of  the 
anus.  The  posterior  surface  forms  an  angle  of  45  degrees  with  the 
horizon,  the  anterior  is  nearly  vertical. 

Of  the  relations  of  the  prostate,  that  of  the  posterior  surface  to  the 
anterior  aspect  of  the  lower  end  of  the  pelvic  portion  of  the  rectum  is  of 
especial  importance  for  it  allows  of  easy  examination  through  the  rectum, 
the  two  being  separated  only  by  a  little  loose  connective  tissue  in  addi- 
tion to  the  capsule  of  the  prostate.  It  is  through  the  rectum  that  we 
can  readily  distinguish  enlargements  of  the  prostate  unless  there  is 
hypertrophy  of  the  "  middle  lobe  "  alone,  when  nothing  can  be  made 
out  by  rectal  touch.  The  lower  ends  of  the  seminal  vesicles  and  the 
ampullae  of  the  vasa  deferentia  are  in  relation  with  the  back  of  the 
"  middle  portion."  On  the  sides  it  is  in  relation  with  the  levator  ani 
muscles  including  their  inner  and  lower  borders,  and  in  "  lateral  pros- 
tatectomy "  we  find  that  it  is  this  muscle  and  its  ensheathing  fasciae 
which  separate  the  prostate  from  the  ischiorectal  fossa.  The  base  of 
the  prostate  is  in  relation  with  the  bladder  for  a  considerably  greater 
distance  behind  than  in  front  of  the  vesical  outlet.  It  is  held  fixed 
in  position  by  the  parts  mentioned  in  relation  with  it,  viz.,  bladder, 


PLATE   XLI  I  I. 


FIG.  87. 


MIDD 
HEMOR- 
RHOIDAL 
ARTERY 


LOWER 
END    OF 
RECTO- 
VESICAL 
POUCH 
PROSTAT 
PERITON 
APONEU- 
ROSIS 

RECTO 
VESICAL 
FASC. 


URACHUS 


VESIC     SEMINAL. 


DORSAL 
VEIN    OF 
PFNIS 


"CAPSULE    OF        lURETHRA 
PROSTATE 


Relative  position  of  tlie  blacklei',  ui'eter,  r-ectum,  prostate, 
seminal  vesicles,  vas  deferens  and  their-  vessels,  viewed 
from  the  right  side.       fJoessel.) 


ENLARGEMENT  OF  THE  PROSTATE.  375 

rectum,  ejaculatory  ducts,  urethra,  levator  ani,  deep  triangular  liga- 
ment and  its  capsule,  formed  of  the  rectovesical  fascia  and  continuous 
below  with  the  deep  triangular  ligament. 

The  capsule  explains  in  part  the  course  of  proHfatic  ahncejiM,  i.  e.,  that 
they  seldom  extend  upward  and  open  into  the  pelvis,  for  this  course 
is  resisted  by  the  pelvic  fascia  reflected  from  the  pelvic  floor  to  the 
base  of  the  prostate  to  form  its  capsule,  and  esj)eoially  by  the  pulx)- 
prostatie  ligaments,  one  of  the  strongest  parts  of  tliis  fascia.  Pros- 
tatic abscesses  extend  in  the  directions  of  least  resistance  and  accord- 
ingly open  most  often  into  the  urethra,  next  in  order  of  frequency  into 
the  rectum.  (See  Relations  of  the  Prostate.)  Less  frequently  they 
open  in  the  perineum,  which  they  reach  by  running  along  the  side  of 
the  rectum,  for  the  dense  triangular  ligament  prevents  their  ])assage 
more  anteriorly.  When  they  perforate  both  the  urethra  and  rectum  a 
urethrorectal  fistula  may  result.  Prostatic  abscess  is  the  result  of  a 
prostatitis,  usually  of  gonorrhoeal  origin.  Such  an  inflammati(»n  mav 
not  go  on  to  abscess  formation  but  stop  short  of  it  with  enlargement 
and  tenderness  of  the  gland,  readily  felt  by  rectum,  and  with  frequent, 
painful  and  difficult  micturition.  The  firmne.ss  of  the  capsule  goes  to 
explain  the  severe  pain  in  acute  prostatitis. 

Between  the  capsule  and  the  organ  itself  is  found  the  prostatic  plexus 
of  veins,  most  marked  at  the  sides  and  in  front,  receiving  at  tin-  latter 
part  the  dorsal  vein  of  the  penis.  The  plexus  connects  with  the 
neighboring  plexuses,  the  hemorrhoidal  of  the  rectum,  the  pudendal 
and  the  vesical,  especially  with  the  latter  with  which  it  forms  the 
vesicoprostatic  plexus.  I^lifchol if li.s  occur  more  commonly  here  than  in 
any  other  veins.  As  these  veins  are  cut  in  lateral  lithotomy  and  other 
operations  they  may  aiFord  an  entrance  for  septic  matter  in  cases  of 
pyremia  following  such  operations.  These  veins  empty  into  the  inter- 
nal iliac  vein. 

In  structure  the  prostate  is  a  inuxrulo-rjldndnlar  organ.  The  f//tinfh 
are  chiefly  at  the  posterior  and  lateral  parts  of  the  organ  and  open  into 
the  floor  of  the  sinuses  of  the  ])rostatic  urethra.  They  sometimes  con- 
tain pathological  concretions.  The  anterior  part  of  the  organ  in 
general  and  the  anterior  commissure  in  particular  contains  l)ut  few 
glands.  The  muscle  tismte  is  largely  of  the  unstriped  variety  but  a  cer- 
tain amount  of  striped  fibers  lie  in  front  of  the  prostatic  urethra  and 
surround  the  lower  part  of  it.  The  unstriped  fiberx  (1)  surround  tlic 
urethra,  forming  the  true  internal  sphincter  of  the  bladder  at  the  upper 
end  of  the  urethra,  where  they  are  continuous  with  the  musi-Ie  of  the 
trigone  and  the  circular  fibers  of  the  bladder ;  (2)  they  are  contlensed 
into  a  muscuh-fibrotis  sheath  between  which  and  the  fibrous  capsule 
lies  the  venous  plexus,  and  (3)  they  form  the  proper  stroma  of  the 
organ. 

in  hypertrophy  of  the  prostate  the  enlargement  is  in  some  cases 
more  glandular,  in  others  more  muscular.  Besides  senile  hypertro- 
phy and  enlargement  from  prostatitis  or  abscess,  the  prostate  may 
become  enlarged  from  tuberculosis,  carcinoma,  myoma  or  adenoma. 


376  PELVIS  AND  PERINEUM. 

The  prostate  may  be  reached  for  operation  through  the  perineum  or 
through  the  bladder,  suprapubically.  It  is  only  separated  from  the 
ischiorectal  fossa  by  the  levator  ani  muscle  and  its  two  investing  fas- 
ciae, the  anal  and  rectovesical.  From  below  it  may  be  most  freely 
exposed  by  a  curved  transverse  incision  in  front  of  the  rectum  (Zucker- 
kandl's  incision),  or  an  antero-posterior  incision  curving  around  the 
left  side  of  the  rectum  (v.  Dittel's  incision). 

The  two  ejaculatory  ducts  (Fig.  95)  are  the  outlet  into  the  pros- 
tatic urethra  of  the  seminal  vesicles  and  the  vasa  deferentia,  by  the  junc- 
tion of  which  they  are  formed  at  the  base  of  the  prostate,  \  to  ^  inch 
behind  the  vesical  outlet.  They  pass  thence  downward  and  forward 
behind  the  middle  lobe  and  between  it  and  the  lateral  lobes  of  the 
prostate,  and  then  along  the  sides  of  the  prostatic  utricle  to  open  on 
either  side  of  the  mouth  of  the  latter  on  the  verumontanum,  in  the  floor 
of  the  prostatic  urethra.  They  are  about  |  inch  long,  converge  slightly 
and  decrease  in  size  from  above  downwards  from  \  to  ^^  of  an  inch. 

In  sagittal  incisio'ns  in  the  prostate  behind  the  urethra,  not  exactly 
median  in  position,  one  of  these  ducts  is  wounded.  This  is  objection- 
able, especially  in  young  subjects,  as  it  may  result  in  closure  of  the 
duct.  An  oblique  radiating  incision,  as  in  lateral  lithotomy,  is  less 
likely  to  wound  them.  Injiammation  may  extend  through  the  duct  to 
the  vas  deferens  and  thence  to  the  epididymis  from  the  bruising  of 
the  aperture  of  the  duct  in  the  extraction  of  a  stone  or  a  fragment  or 
in  the  passage  of  an  instrument,  or  from  the  extension  of  an  urethritis. 
This  and  not  metastasis  is  the  usual  origin  of  epididymitis,  as  is  indi- 
cated by  slight  enlargement  and  tenderness  of  the  vas,  though  attention 
is  not  usually  called  to  it  by  any  marked  symptoms.  The  injection 
into  the  prostatic  urethra  of  solutions  of  nitrate  of  silver,  etc.,  in  cases 
of  derangement  of  the  sexual  function  is  intended  to  act  upon  the 
openings  of  the  ejaculatory  ducts. 

A  peculiar  and  occasional  condition  known  as  "  spermatic  colic," 
characterized  by  sharp  pain  after  sexual  intercourse  or  defecation  and 
sometimes  by  the  absence  of  ejaculation  and  the  presence  of  blood  in  the 
urine,  is  due  to  an  obstruction,  more  or  less  complete,  of  the  ejaculatory 
duct  by  spermatic  granules  held  together  in  a  mucous  vehicle.  It  may 
be  cured  by  the  passage  of  a  sound  with  or  without  pressure  of  the  finger 
in  the  rectum. 

The  Seminal  Vesicles. 

The  two  vesiculffi  seminales  (Figs.  85  and  87)  are  symmetrically 
placed  on  the  two  sides  between  the  base  of  the  bladder  and  tlie  front 
of  the  pelvic  portion  of  the  rectum.  They  cvfend  from  the  ejaculatory 
ducts,  at  the  base  of  tiie  prostate,  upward,  backward  and  outward  for 
about  two  inches,  at  an  angle  of  50°  to  00°  with  the  horizon.  Their 
position  varies  somewhat  with  the  condition  of  the  bladder  and  follows 
that  of  the  rectum,  for  the  posterior  j)art  of  their  sheath  is  composed 
of  that  part  of  the  rectovesical  fascia  which  forms  the  fascial  covering 
of  the  rectum  and  thus  connects  them  closely  with  the  rectum. 
The  lower  ends  of  the  vesicles  are  palpable  through  the  rectum  above 


THE  SEMINAL    VESICLES.  ^11 

the  base  of  the  prostate,  especially  if  the  liand  presses  the  surface 
about  the  anus  strongly  upward  and  the  prostate  is  not  enlarged. 
The  seminal  vesicles  are  more  readily  palpated  when  the  bladder  is 
full  and  when  they  are  enlarged  or  hardened  i)y  disease.  By  the 
finger  in  the  rectum  we  can  press  downward  the  contents  of  the  vesi- 
cles into  the  prostatic  urethra  and  thence  externally.  The  same  result 
may  follow  the  passage  of  large  hard  fecal  masses  through  the  rectum, 
which  may  cause  a  nervous  man  to  fancy  he  has  spermatorrho'a.  The 
upper  third  of  the  seminal  vesicles  is  covered  behind  by  the  peritoneum 
of  the  rectovesical  pouch,  which  separates  this  portion  from  the  rectum. 
This  pouch  sinks  somewhat  lower  in  the  space  between  the  vesicles. 

Anteriorh/  the  capsule  of  the  seminal  vesicles  is  connected  by  loose 
tissue  with  the  base  of  the  bladder.  The  vesicles,  togetlier  with  the 
ampuUse  of  the  vasa  deferentia  along  their  mesial  borders,  lie  ah)ng 
the  lateral  borders  of  the  trie/one  of  the  bladder  and  the  fossa  retro- 
ureterica,  so  that  in  distension  of  the  bladder  the  latter  fossa  projects 
between  the  seminal  vesicles.  The  triangular  area  between  the  lower 
ends  of  the  vesicles  and  ampulhe  is  the  area  where  the  rectum  and 
bladder  are  closely  connected  without  the  intervention  of  peritoneum 
(see  page  360).  The  upper  ends  or  bases  of  the  vesicles  are  G  to  7  cm. 
apart,  they  approach  the  lateral  pelvic  walls  and  overlap  the  lower  ends 
of  the  »/7'/rr.s' just  before  the  latter  pierce  the  bladder. 

The  vesicles  are  loosely  connected  with  their  capauh'H  from  whicii 
they  are  readily  shelled  out.  When  so  shelled  out  we  see  that  their 
lobulated  appearance  is  due  to  the  convolutions  of  a  blind  tube,  about 
four  or  more  inches  long,  and  to  numerous  blind  sacculi  and  lateral 
branches.  The  capsule  is  continuous  with  that  of  the  prostate  and 
with  the  rectovesical  fascia,  and  contains  several  scattered  muscle 
fibers.  Enclosed  within  its  capsule  each  vesicle  presents  an  elongated 
triangular  shape,  the  lower  and  smaller  end  of  which  opens  by  a  free 
aperture  into  the  lateral  wall  of  the  ampulla  to  form  the  ejaculatory 
duct.  The  seminal  vesicles  vary  much  in  size  not  only  in  different  per- 
sons but  on  the  two  sides  of  the  same  person.  Cases  are  also  reported 
where  one  or  both  vesicles  have  l)ecn  found  wanting,  the  latter  con- 
dition usually  in  anorchids. 

The  vesicles  .secrete  an  all)iunin()us  Huid  which  usually  contains  a  few 
spermatozoa  which  have  wandered  there  by  their  own  motility,  for  it  is 
now  thought  improbable  that  they  serve  as  reservoirs  for  the  semen. 
The  contents  of  the  vesicles  add  to  the  bulk  of  the  fluid  ejaculated. 

The  vesicles  from  their  position,  about  the  center  of  the  pelvis,  are 
well  protected  from  injnri/,  which  rarely  aflects  them.  luflnminntiou 
may  extend  into  the  seminal  vesicles  from  the  prostate  through  the 
ejaculatory  ducts,  and,  if  an  abscess  forms,  the  relations  of  the  vesicles 
show  that  it  may  l)reak  into  the  bladder,  reetum  or  peritoneal  cavity,  and 
that  it  may  involve  the  vas,  the  prostate  or  the  ureter.  Tuberculosis  of  the 
seminal  vesicles  is  not  uncommon  and  forms  one  of  the  varieties  of 
genito-urinary  tuberculosis.  It  is  usually  an  extension  from  neighbor- 
ing parts. 


378  PELVIS  AND   PERiyEUM. 

The  seminal  vesicles  may  be  exposed  and  removed  through  a  curved 
transverse  incision  a  little  in  front  of  the  anus  (Zuckerkandl's  method) 
or  a  median  incision  encircling  the  anus  on  one  side.  The  anterior 
fibers  of  the  levator  ani  are  divided,  exposing  the  prostate,  and  then 
the  rectum  is  separated  from  the  bladder,  exposing  the  seminal  vesicles. 

The  Vas  Deferens.     (Fig.  87.) 

This  continuation  of  the  epididymis,  or  efferent  duct  of  the  testis, 
extends  from  the  globus  minor  to  the  ejaculatory  duct.  In  the  scro- 
tum it  lies  behind  the  testis  and  internal  to  the  epididymis,  thence 
it  extends  upward  to  the  external  ring  as  one  of  the  constituents  of  the 
spermatic  cord,  behind  and  internal  to  the  other  constituents  of  the  cord. 
In  this  position  it  is  readily  felt  and  avoided  in  operations  for  varico- 
cele, or  exposed  and  divided  in  the  operation  of  vasectomy,  proposed 
as  a  substitute  for  castration  in  prostatic  hypertrophy.  It  is  readily 
felt  as  a  uniform,  firm,  round,  whipcord-like  structure.  Its  firmness 
is  due  to  the  thickness  of  its  walls  as  compared  with  the  size  of  the 
lumen.  When  affected  by  tubercular  disease  it  is  characteristically 
nodular.  In  cases  of  inversion  of  the  testis  its  position  is  reversed, 
lying  in  front  of  the  testis  and  the  other  elements  of  the  spermatic 
cord. 

At  the  external  abdominal  ring  it  lies  behind  and  internal  to  the 
neck  of  the  sac  of  an  oblique  inguinal  hernia  and  external  to  that  of 
a  direct  inguinal  hernia.  It  may  become  adherent  to  the  coverings  of 
a  hernia,  especially  in  cases  of  long  standing.  After  entering  the 
abdomen  through  the  internal  ring  it  soon  diverges  from  the  spermatic 
vessels  and,  looping  above  the  arch  of  the  deep  epigastric  artery,  enters 
the  jjelris  near  the  iliopubic  eminence.  It  then  runs  backward  and 
downward  on  the  lateral  pelvic  wall,  and  thence  onto  the  postero- 
lateral aspect  of  the  bladder.  In  this  part  of  its  course  it  crosses  the 
external  iliac  vein,  obliterated  hypogastric  artery  and  obturator  vessels 
and  nerve. 

On  the  bladder  it  lies  on  the  vesical  side  of  the  obliterated  hypogastric 
artery  and  the  lower  end  of  the  ureter,  separated  from  the  latter  by  a 
layer  of  perivesical  fat  one  half  inch  thick.  After  crossing  over  the 
ureter  it  bends  down  on  its  mesial  side  onto  the  base  of  the  bladder, 
where  it  lies  between  it  and  the  rectum,  adjacent  and  internal  to  the  ves- 
iculae  seminales.  Here  it  becomes  enlarged  and  somewhat  sacculated  as 
the  ampulla  whose  relations  are  similar  to  those  of  the  seminal  vesicles 
already  described  (q.  v.).  Near  the  base  of  the  prostate,  and  the  in- 
ferior angle  of  the  triangular  area  where  the  bladder  and  rectum  are 
in  contact,  it  narrows  down  and  is  joined  by  the  vesiculse  seminales  to 
fi)rm  the  ejaculatory  duct. 

The  entire  pelvic  portion  of  the  vas,  except  that  at  the  base  of  the 
bladder,  is  subperitoneal  and  quite  closely  attached  to  the  peritoneum, 
so  that  wlien  the  latter  is  raised  it  tends  to  follow  it. 

The  infection  from  a  urethritis  may  extend  along  the  vas  to  the  epi- 
didymis, giving  rise  to  epididymitis.     In  such  cases  the  vas  becomes 


THE   UTERUS.  379 

swollen  to  the  size  of  a  lead  pencil  and  tender,  but  the  inflammation 
of  the  vas  speedily  subsides  and  generally  leaves  no  trace.  The  am- 
pulla of  the  vas  may  be  palpated,  exposed  and  oj)erated  upon  in  the 
same  way  as  the  seminal  vesicles. 

The  arfcri/  of  the  vas  deferens,  derived  either  frf)m  the  superior  or 
one  of  the  inferior  vesical  arteries,  forms  an  imjjortant  andMomrm^  with 
the  spermatic  artery  at  the  lower  end  of  the  epididymis,  which  is  suffi- 
cient to  nourish  the  testis  when  the  spermatic  artery  is  ligated  in  the 
operation  for  varicocele. 

THE    FEMALE    PELVIC    GENITAL    ORGANS. 
The  Uterus. 

The  uterus  lies  within  the  pelvis  between  the  bladder  and  the  rectum 
and,  together  with  its  lateral  or  broad  ligaments,  divides  the  pelvic 
cavity  into  an  anterior  or  utero vesical  and  a  posterior  or  uterorectal 
compartment.  Its  size  and  shape  vary  with  age  and  many  physiolog- 
ical and  jwthological  conditions.  In  shape  it  is  pyriform  and  flattened 
from  before  backward,  except  when  affected  by  unsymmetrical  new 
growths  like  fibromyomata,  cancer,  etc.  The  fundus  is  on  a  level  with 
the  uterine  ends  of  the  Fallopian  tubes  in  nulliparae  and  about  1  cm. 
above  in  multipara.  In  the  iiifanf  and  the  child  before  ])ubertv  it  is  real- 
tively  small  in  size,  the  cervix  is  larger  than  the  Ixxly,  and  the  intra- 
vaginal  segment  of  the  cervix  is  relatively  large.  In  the  uterus  of  a 
young  adult  virgin  the  length  is  about  equally  divided  between  the 
cervix  and  the  body.  In  the  nnl/ijjnrou.s  married  woman  the  body 
becomes  somewhat  larger  than  the  cervical  portion.  When  completely 
involuted  after  childbirth  the  uterus  is  always  somewhat  larger  tiian 
before  conception  and  the  length  of  the  body  is  twice  that  of  the 
cervix.  In  old  age  the  entire  organ  atrophies  and  this  process  begins 
after  functional  activity  ceases  at  the  menopause.  In  the  nulliparous 
adult  the  length  is  about  2J  inches,  the  greatest /vz-ra J///  H  inches; 
after  childbirth  the  dimensions  are  about  one  fifth  greater. 

The  weight  in  nulliparae  is  about  an  ounce,  in  multipara^  an  ounce 
and  a  half,  in  old  age  it  may  be  as  little  as  one  to  two  drachms,  while 
at  full  term  it  may  vary  between  twenty-two  and  forty-six  ounces. 
The  weight  is  somewhat  increased  during  menstruation.  Increase  of 
weight  may  be  due  to  pregnancy,  inflammation,  now  growths,  etc.,  and 
may  cause  various  malpositions. 

Position. — The  uterus  of  the  infant  and  rhi/il  projects  above  the 
pelvic  brim  and  lies  almost  wholly  in  the  alxlomen,  compressed  be- 
tween the  bladder  and  rectum  and  without  flexion  as  a  rule.  Btjorc 
puberty  it  comes  to  lie  entirely  below  the  pelvic  brim,  but  above  a 
horizontal  jilane  passing  through  the  up|H'r  end  of  the  symphysis,  and 
remains  so  unless  enlarged  bv  j)regnaney  or  by  jiathologii-al   processes. 

The  uterus,  especially  the  body,  is  very  momh/r  so  that  its  axis  is 
without  doubt  subject  to  considerable  variation  within  normal  limits. 
According  to  some  it  ordinarily  coincides  with  the  long  axis  of  the 


380  PELVIS  AKD  PERINEUM. 

body,  but  it  may  incline  forward  as  much  as  15°  or  20°  wlien  the 
bladder  is  empty,  and  the  full  rectum  pushes  it  forward  and  deflects 
it  slightly  to  the  right.  Others  give  its  axis  as  in  line  with  the  axis 
of  the  pelvic  inlet,  and  others  still  (Joessel,  Waldeyer)  as  antefe.rcd  from 
70°  to  100°,  and  also  anteverted.  According  to  the  latter  author  the 
external  os  is  on  a  level  with  the  upper  end  of  the  symphysis,  in  a 
transverse  vertical  plane  passing  through  the  spines  of  the  ischium, 
and  the  axis  of  the  cervix  is  in  line  with  that  of  the  pelvis  at 
this  point.  The  condition  of  the  neighboring  intestinal  coils  may 
also  affect  its  position.  As  the  uterine  axis  forms  an  angle  with 
that  of  the  vagina  the  lower  end  of  the  cervix,  including  the  anterior 
and  p,osterior  lips  and  the  external  os,  abut  against  the  posterior  vagi- 
nal wall. 

Fixation. — The  broad  or  lateral  ligaments  fasten  both  the  body  and 
cervix  to  the  lateral  walls  and  floor  of  the  pelvis.  The  body  is  also 
supported  by  the  round  ligaments  attached  to  its  cornua  and  so  directed 
as  to  hinder  its  posterior  or  lateral  displacement  and  to  some  extent  its 
downward  prolapse.  The  other  ligaments  of  the  uterus,  both  true 
(uterosacral)  and  false  (anterior  and  posterior)  steady  the  cervix  fore 
and  aft.  In  addition  the  cervix  is  fixed  by  its  attachment  to  the  blad- 
der and  vagina  so  that  it  is  the  most  fixed  part  of  the  uterus.  When 
the  uterus  becomes  enlarged  from  pregnancy  or  otherwise  the  ligaments 
stretch  or  lengthen  to  accommodate  themselves  to  the  new  conditions. 
During  involution  of  the  uterus  after  childbirth  the  ligaments  again 
contract  and  shorten,  but  if  the  uterus  remains  subinvoluted  or  the 
patient  gets  up  too  soon,  and  especially  if  she  strains  herself  by  work 
before  the  balance  between  the  uterus  and  its  ligaments  is  reestablished, 
there  is  danger  of  uterine  displacement,  as  it  is  not  properly  supported. 

Relations. — As  the  rectum  lies  behind  it  we  can  examine  the  uterus, 
to  determine  its  size  and  position,  by  palpation  through  the  rectum 
almost  if  not  quite  as  well  as  through  the  vagina,  especially  if  there  is 
retroflexion  or  retroversion. 

Between  the  uterine  body,  the  supravaginal  portion  of  the  cervix 
and  the  upper  part  of  the  vagina  in  front  and  the  rectum  behind  lies 
the  rectouterine  pouch  of  peritoneum  (pouch  or  cul  de  sac  of  Douglas), 
bounded  laterally  by  the  posterior  false  ligaments  of  the  uterus,  enclos- 
ing the  uterosacral  ligaments.  Douglas'  pouch  normally  contains 
coils  of  small  intestine  and  perhaps  part  of  the  sigmoid  loop.  It  is 
readily  examined  by  the  finger  per  rectum  or  per  vaginam,  or  opened 
into  through  the  posterior  vaginal  fornix,  and  it  is  the  seat  of  retro- 
uterine hematocele.  The  peritoneum  is  reflected  from  the  front  of  the 
isthmus  onto  the  bladder  to  form  the  uterovesical  pouch.  This  contains 
coils  of  intestine  and  is  much  shallower  than  the  pouch  of  Douglas. 
The  subperitoneal  connective  tissue  continues  down  below  this  reflection 
of  peritoneum  and  separates  the  cervix  from  the  bladder,  allowing  the 
separation  of  the  two  along  this  plane  in  hysterectomy.  This  layer  is 
continuous  with  that  found  at  the  sides  of  the  cervix,  between  the 
layers  of  the  broad  ligaments,  and  with  a  more  scanty  amount  beneath 


PLATE   XLIV 


FIG.  88. 


UHETEB 
OBTURATOR 

ARTERY 


NTERNAL    ILIAC 

ARTERIES 
EXTERNAL    ILIAC 

ARTERY 
VESICO-VACINAL 

ARTERY 


The  female  pelvis  and  pelvic  viscera  fr-om  above,  ih<-    uterus 
and  adnexa  being  drawn  forward.     (Tesiut. 


THE  CERVIX.  881 

the  peritoneum  covering  the  back  of  tlie  supravaginal  jx^rtiou  of  the 
cervix.  Tlie  cervix  is  thus  seen  to  be  ciido.scd  in  a  layer  of  /oouc  ron- 
ncdivc  tissue  of  varying  thickness,  continuous  with  the  subperitoneal 
connective  tissue.  This  facilitates  the  amputation  of  the  cervix  with- 
out opening  the  peritoneal  cavity  (/.  r,,  extrajx'ritoncal). 

From  the  above  we  see  the  relation  of  the  uterus  to  the  peritoneum 
which  covers  the  anterior  and  posterior  surfaces  and  the  upper  end  of 
the  body,  and  the  supravaginal  portion  of  the  posterior  part  of  the 
cervix.  It  is  reflected  from  the  sides  of  the  body  and  cervix  to  form 
the  broad  ligaments. 

New  growths,  like  carcinoma  of  the  uterus,  may  extend  onto  the 
rectum  or  bladder  and  vice  versa,  and  the  ureters,  on  account  of  their 
close  relations  to  the  cervix,  may  become  occluded  from  the  extension 
of  a  carcinoma  of  the  latter,  and  uraemia  result. 

The  Cervix. — Of  i\\e  three  zones  (Fig.  !)1  )  into  which  the  cylindrical 
cervix  is  divided  the  lower  or  intravaginal  zone  projects  into  the  upper 
part  of  the  vagina  at  such  an  angle  that  its  lower  end  abuts  against 
the  posterior  vaginal  wall.  This  lower  end  contains  the  external  os,  or 
lower  opening  of  the  uterine  canal,  bounded  by  a  lower  anf( rior  /iji, 
short  and  thick,  and  a  posterior  lip  whicli  is  longer  than  tlie  anterior 
by  reason  of  the  greater  height  of  the  posterior  vaginal  fornix.  The 
orifice,  a  transverse  fissure  a  quarter  of  an  inch  broad  in  the  virgin, 
becomes  irregular  after  childbirth  owing  to  the  notciiing  of  its  lips,  so 
that  by  palpation  of  the  os  we  can  say  whether  a  woman  has  borne 
children.  This  intravaginal  portion  of  the  cervix  can  be  seen  through 
the  speculum  or  examined  by  the  finger  in  the  vagina,  and  is  more  ex- 
posed to  lesions  of  all  sorts  than  other  parts  of  the  cervix,  especially 
to  "  erosions  "  and  cancerous  ulcerations.  The  first  part  that  we  see 
or  feel  on  examination  is  the  anterior  lip. 

The  cervix  may  become  hypertrophied  so  as  to  be  elongated  and  pro- 
ject downward  into  the  vagina  unusually  far.  This  may  resemble  a  j>ro- 
lapse,  but  if  we  try  to  pusli  it  up,  usually  an  easy  matter  in  prolapse, 
resistance  and  jiain  are  at  once  met  with  from  the  tension  of  its  connec- 
tions. This  elongation  may  affect  either  the  intra-  or  supravaginal  por- 
tion of  the  cervix.  In  the  former  case  the  vaginal  fornices  are  deep- 
ened, in  the  latter  they  are  not.  Such  a  cervix  may  even  interfi-re  with 
coitus,  and  a  conical,  ]M)inted  cervix  is  unfiivorable  to  romrjttinn  and 
may  be  a  cause  of  sferi/iti/.  Another  cause  of  sterility  as  well  as  of 
dysmenorrhoca  is  furnished  by  an  (Ureaia  or  narrowing  of  the  os  ex- 
ternum, by  no  means  rare.  The  cervix  may  be  enormously  enftnr/cd 
from  chronic  disease.  During  pre(/n(fn('i/  it  becomes  broad  and  soft 
and  is  drawn  up  from  the  cavity  of  the  vagina,  the  extt'rnal  os  being 
occluded  by  a  plug  of  mucus.  The  intravaginal  portion,  relatively 
large  and  prominent  in  female  children,  may  nearly  completely  disap- 
pear in  o/d  women,  and  sometimes  in  younger  mnltipano.  It  j^ossesses 
so  /itt/e  sensation  that  we  can  insert  sharp  hooks  to  pull  it  down  and 
make  all  manner  of  applications  to  it  without  j)rodueing  much  if  anv 
pain. 


382  PELVIS  AND  PERINEUM. 

The  zone  of  vaginal  attachment,  about  one  fifth  inch  deep,  is  ob- 
liquely placed,  extending  higher  behind  than  in  front,  thus  making  the 
posterior  lip  longer  and  the  posterior  vaginal  fornix  deeper. 

The  supravaginal  zone  represents  about  half  of  the  cervix  behind 
and  two  thirds  in  front.  It  is  connected,  as  we  have  seen  above,  with 
the  bladder  anteriorly,  while  posteriorly  it  is  covered  by  peritoneum 
and  enters  into  the  anterior  wall  of  Douglas^  pouch.  Perhaps  the 
most  important  relations  of  the  cervix  are  found  at  its  sides  which  are 
connected  with  the  broad  ligaments,  in  which  at  this  level  lie  the  uterine 
vessels  and  the  ureter.  The  uterine  artery  passes  nearly  horizontally 
inward  in  the  base  of  the  broad  ligament  to  the  supravaginal  portion 
of  the  cervix,  accompanied  by  the  large  uterine  veins,  arranged  in  a 
plexiform  manner. 

One  of  the  most  important  topographical  points  in  the  female  pelvis  is 
the  crossing  of  the  uterine  artery  in  front  of  the  ureter.  This  occurs  on 
a  level  with  the  intravaginal  portion  of  the  cervix  and  about  2  cm. 
(four  fifths  of  an  inch)  from  the  cervix.  The  ureter  passes  through  the 
plexus  of  the  uterine  veins.  The  fact  of  the  crossing  is  important  for 
it  occurs  close  to  where  we  tie  or  clamp  the  uterine  vessels  in  remov- 
ing the  uterus  or  cervix.  Hence  there  is  danger  of  wounding  the 
ureter,  a  danger  which  is  real  for  it  has  occurred  in  many  reported 
cases.  After  crossing  behind  the  uterine  arteries  the  two  ureters,  con- 
verging slightly,  incline  somewhat  forward  so  as  to  reach  the  front  of 
the  sides  and  then  the  anterior  wall  of  the  vagina. 

Displacements. — As  we  have  seen  (Fixation,  page  380)  the  cervix 
is  the  most  fixed  part  of  the  uterus,  while  the  ligaments  holding  the 
body  allow  it  more  freedom  of  motion.  The  slightly  constricted  part 
{isthmus),  where  the  more  fixed  cervix  joins  the  heavier  and  more  mov- 
able body,  is  an  exposed  and  iceah  point  where  ante-  and  retroflexions 
occur,  the  body  of  the  uterus  bending  and  the  cervix  retaining  its 
proper  position.  In  anteflexion  the  body  is  bent  forward  onto  the 
bladder  and  we  can  palpate  it  by  combined  vaginal  and  abdominal 
palpation,  while  in  retroflexion  the  body  occupies  Douglas'  pouch  and 
presses  upon  the  rectum,  through  which  or  the  vagina  it  may  be  readily 
palpated.  A  certain  degree  of  anteflexion  is  not  pathological  but 
probably  normal. 

If  the  uterus  is  ante-  or  retroverted  it  seesaws  on  the  Isthmus  as  a 
transverse  axis  so  that  if  the  body  moves  in  one  direction  the  cervix 
is  forced  in  the  opposite  direction.  Thus  in  anteversion  the  body 
lies  upon  the  bladder  while  the  vaginal  portion  of  the  cervix  tilts 
up  and  back  into  the  posterior  vaginal  fornix  ;  in  retroversion  the 
cervix,  tilted  forward,  presses  against  the  bladder  while  the  body  of 
the  uterus  presses  against  the  rectum.  In  either  of  these  cases  it  may 
be  difficult  to  make  the  external  os  present  at  the  end  of  a  speculum. 
Any  of  these  malpositions  may  tend  to  prevent  conception,  by  reason 
of  the  position  of  the  os  or  the  obstruction  due  to  the  sharply  bent 
canal.  Anteversion  is  said  to  be  more  common  among  childless 
women,  retroversion  among  women  who  have  borne  children,  especially 


CAVITY  AND    WALL   OF  THE   UTERUS.  383 

if  after  labor  they  have  been  bandaged  too  tightly  and  too  long  in  the 
supine  position. 

As  the  round  lifjanientH  prevent  backward  displacement  of  the  uterus 
their  relaxation  allows  of  retroversion,  and  their  shortening  produced 
anteversion,  which  may  also  be  caused  by  the  retraction  of  the  utero-mcrnl 
ligaments,  In'  pulling  the  cervix  backward  and  thus  tilting  the  body 
forward.  In  anteversion  or  anteflexion  the  body  of  the  uterus  may  so 
press  upon  the  hladdcr  as  to  cause  much  irrildhHity.  In  retroversion 
the  cervix  presses  upon  the  bladder  near  its  outlet  so  as  to  cause  more 
irrital)ility  of  the  bladder  than  the  pressure  of  the  anteflexed  or  ante- 
verted  uterus  upon  its  upper  part.  In  the  same  manner  the  body  in 
retroversion  or  retroflexion  and  the  cervix  in  anteversion  may  so  press 
upon  the  rectum  as  to  cause  rectal  tenesmus  and  diflicult  and  painful 
defecation  and  thereby  induce  constipation. 

The  uterus  displaced  in  any  of  the  above  ways  may  regain  its 
normal  position  unless  adhesions  occur  and  fasten  it  to  the  viscus 
against  which  it  presses,  whereby  the  symptoms  due  to  pressure  become 
chronic.  Either  form  of  flexion  may  cause  di/smenorrlura  by  obstruct- 
ing the  escape  of  the  menstrual  flow.  When  the  supj)orting  ligaments 
are  relaxed  and  this  condition  is  combined  with  a  weakening  of  the 
support  of  the  perineum,  following  its  rupture,  and  an  abnormally 
heavy  uterus,  the  latter  may  sink  or  become  prolapsed  so  as  to  present 
at  the  vulva  or  even  to  lie  partly  or  wholly  outside  the  vulva.  A 
much  rarer  condition,  and  one  more  difficult  to  treat,  is  where  the  uterus 
is  inverted  or  turned  inside  out,  which  may  be  due  to  the  traction  of  a 
polypoid  submucous  fibroid. 

The  small  cavity  of  the  uterus  is  a  mere  fissure.  The  cavity  of  the  body 
is  triangular  in  shape  with  an  ojiening  at  each  angle,  the  Fallopian  tulies 
above  and  the  narrow  internal  os  l>elow.  The  latter  oj)c'ning  is  at  the 
upper  end  of  the  fusiform  cervical  canal  which  ends  below  in  a  trans- 
verse fissure,  the  external  os.  The  narrowness  of  the  os  internum  may 
be  such  as  to  be  an  obstacle  to  the  menstrual  flow  and  a  cause  of  dys- 
menorrhcea.  In  old  age  it  becomes  still  more  contracted  and  even 
closed.  The  cervical  canal  may  be  gradually  yet  fairly  quickly  dilated 
so  as  to  allow  inspection  and  digital  examination  of  the  uterus  and 
even  the  enucleation  of  large  tumors.  The  mucfnis  rnnnhranr  of  the 
cervical  canal  secretes  a  viscid  alkaline  mucus  and  path* (logically  its 
mucous  glands  are  liable  to  become  vesicular,  when  they  are  sometimes 
known  as  ovula  Xabothi.  The  motion  of  the  cilia  of  the  uterine 
mucosa  is  downward  toward  the  os  externum.  The  length  of  the 
uterine  cavity  averages  about  two  inches  in  nulli|)ane  and  2|  to  2A 
inches  in  multipane.  We  can  determine  the  length  by  the  uterine 
sound. 

As  there  is,  strictly  speaking,  no  cavity,  the  bulk  of  the  uterus  is 
made  up  of  its  thick  wall.  A  part  from  its  remarkably  thick  mucoiiH  uum- 
hrane,  which  is  thickened  and  then  i)artly  cast  off  at  the  monthly 
periods  and  becomes  the  deeidua  during  gestation,  this  thick  wall  con- 
sists principally  of  unstriped   niusde  Jibers.     This  tissue,  arranged   in 


384  PELVIS  AND  PERINEUM. 

three  imperfect  layers,  is  remarkable  for  its  hypertrophy  and  new 
growth  during  pregnancy,  and  it  is  largely  by  its  contraction  that  the 
foetus  is  expelled.  The  muscle  tissue  of  the  uterus  is  continuous  with 
that  of  the  utero-sacral,  round,  utero-ovarian,  and  broad  ligaments,  and 
that  of  the  Fallopian  tubes,  vagina  and  bladder. 

In  this  tissue  in  any  part  of  the  uterus,  but  more  often  in  the  body, 
develop  the  common  fibroids,  myomata  or  fibromyomata,  as  they  are 
variously  called.  These  may  be  single  or  more  often  multiple  and 
may  attain  a  very  large  size  ;  one  of  one  hundred  and  forty  pounds  has 
been  recorded,  but  as  a  rule  they  do  not  attain  the  size  of  the  largest 
ovarian  tumors.  In  their  evolution  they  often  acquire  a  partial  or  a 
complete  capsule  and  may  protrude  on  the  surface  (^subperitoneal  variety), 
or  into  the  cavity  (submucous  variety),  or  they  may  remain  well  en- 
closed in  the  walls  (interstitial  variety).  They  occur  during  menstrual 
activity,  they  tend  to  degenerate  after  the  menopause  and  sometimes 
become  involuted  with  the  rest  of  the  uterus  after  parturition.  They 
are  particularly  common  among  negroes.  The  submucous  variety  is 
apt  to  cause  severe  bleeding  and  hence  should  be  removed  early.  The 
subserous  variety  is  liable  to  adhesions  from  local  peritonitis.  They 
may  prevent  conception,  cause  miscarriage  or  complicate  parturition, 
according  to  their  size  and  situation. 

The  uterus,  enlarged  from  pregnancy  or  other  cause,  may  press  upon 
the  iliac  vein,  causing  hemorrhoids  or  varicose  veins  of  the  legs ;  on 
the  lumbar  or  sacral  nerves,  causing  neuralgia  and  cramps  ;  or  on  the 
renal  veins  or  kidneys,  causing  albuminuria,  etc. 

Owing  to  its  small  size,  its  great  motility  and  the  protection  afforded 
by  the  pelvis  the  unimpregnated  uterus  is  rarely  ivounded.  The  preg- 
nant uterus  may  be  ruptured  by  violence  or  by  its  own  contraction 
during  labor,  especially  if  the  passage  of  the  foetus  is  obstructed. 
The  rupture  is  usually  near  the  junction  of  the  cervix  with  the  body. 

Vessels. — The  uterus  is  supplied  by  the  uterine  arteries  from  the 
internal  iliac  and  the  ovarian  from  the  abdominal  aorta.  The  uterine 
artery  of  either  side  passing  horizontally  inward  in  the  base  of  the 
broad  ligament  crosses  in  front  of  the  ureter  (see  p.  382),  and  reaches 
the  side  of  the  cervix  whence  it  runs  up  along  the  side  of  the  uterus, 
between  the  folds  of  the  broad  ligament.  At  the  cornu  or  angle  it 
anastomoses  freely  with  the  ovarian  artery.  In  young  individuals  the 
artery  lies  |-1  cm.  from  the  uterus  and  still  further  removed  from  the 
cervix  and  the  lower  part  of  the  body.  After  repeated  pregnancies  it 
comes  to  lie  nearer  the  uterus  and  becomes  more  tortuous  so  that  in 
operations  it  is  more  difficult  to  separate  the  artery  from  the  uterus. 

At  the  uterine  end  of  the  round  ligament  the  small  funiculitr  artery, 
accompanying  the  round  ligament,  anastomoses  with  the  uterine  and 
ovarian  arteries.  Numerous  transverse  branches  from  the  uterine 
arteries  supply  the  uterus  and  anastomose  across  the  median  line.  Ow- 
ing to  this  fact  and  the  free  anastomosis  with  the  ovarian  artery,  a  liga- 
ture may  be  placed  around  the  uterus  without  affecting  the  circulation 
above  or  below. 


THE  OVARY.  385 

By  a  lateral  incimon  into  the  upper  end  of  the  vagina,  opening  into 
the  base  of  the  broad  liganunts,  the  uterine  arteries  may  be  pulled 
down  and  tiefl,  the  relation  of  the  artery  to  the  ureter  being  carefully 
borne  in  mind,  as  it  should  be  also  in  securing  and  dividing  the  artery 
in  hysterectomy.  The  veins  form  large  jjlexuges  and  accompany  the 
corresponding  arteries. 

The  lymphatics  from  the  cervix  accompany  the  uterine  veins  and 
enter  the  pelvic  node.s,  beneath  the  bifurcation  of  the  iliac  artery,  thone 
from  the  hofJi/  accompany  the  ovarian  veins  and  enter  the  lunthfir  nodea. 

Development. — The  uterus  and  vagina  are  formed  l)y  the  fusion  of 
the  lower  cuds  of  the  two  (hict.s  of  Midler,  tiie  two  unuuited  upper  end.s 
of  which  form  the  Fallopian  tubes.  The  bicoi'ned  and  double  uteri 
are  due  to  the  failures  of  this  fusion  in  whole  or  in  ])art,  and  thev  mav 
be  associated  with  a  partial  or  comj)lete  septum  dividing  the  vagina. 
Pregnancy  as  well  as  many  of  the  pathological  conditions  may  be  con- 
fined to  one  half  or  one  cornu  of  a  malformed  uterus. 

The  uterus  is  reached  for  operation  through  a  median  cceliotomy  or 
through  the  vagina.  In  its  removal  (lii/f^terectomi/)  its  connections  with 
the  broad  ligaments,  vagina  and  bladder  are  the  principal  things  to  be 
divided  or  separated.  Kemember  that  its  two  arteries  reach  it  through 
the  broad  ligament,  the  ovarian  at  its  cornu,  the  uterine  opposite  the 
cervix.  We  repeat  again  that  the  relation  of  the  ureters  to  the  cervix 
and  the  uterine  vessels  must  be  borne  in  mind. 

The  Ovary. 

The  ovary  is  a  paired  organ,  sluiped  like  a  broad  almond  whose 
length  is  1}  inches,  breadth  |  inch,  thickness  h  inch.  Its  ireight  is  about 
100  grains  in  the  adult,  the  right  being  usually  a  little  larger.  Before 
puberty  it  is  small,  it  enlarges  at  puberty,  and  after  the  menopause 
atrophies  very  much. 

Position. — We  may  describe  a  typical  position  of  the  ovary  remem- 
bering that,  being  a  movable  body,  it  may  temporarily  occupy  other 
positions  without  causing  any  disturbance.  The  latter  positions  may 
more  readily  change  into  abnormal  positions  which  do  cause  functional 
disturbances. 

When  the  other  pelvic  organs  are  normal  and  there  have  not  been 
repeated  pregnancies,  the  typical  position  of  the  ovary  in  the  upright 
posture  is  with  its  long  axis  vertical,  its  attarlied  border  in  front  and 
slightly  external,  its  free  border  behind  and  slightly  internal,  toward 
the  rectum,  its  lateral  surface  against  the  lateral  pelvic  wall  in  the 
fossa  ovarica,  and  its  nn:^-ifd  surface  looking  into  the  ]>elvis. 

The  fossa  ovarica,  or  the  depression  on  the  inner  surface  of  the  in- 
ternal obturator  muscle  in  which  the  ovary  lies,  varies  much  in  deptii 
and  is  bounded  above  and  in  front  by  the  superior  vesical  artery, 
behind  by  the  ureter  and  uterine  artery,  below  and  in  front  by  the  lat- 
eral attachment  of  the  broad  ligament.  Lodged  in  this  fossa  the  lat- 
end  surf  ice  o{^  the  ovary  is  not  visible  and  the  attadied  border,  upper 
end,  and  a  variable  amount  of  the  free  border  antl  mesial  surface  are 


386  PELVIS  AND  PERINEUM. 

covered  by  the  Fallopian  tube,  so  that  but  little  of  the  ovary  may  be  vis- 
ible on  inspecting  the  pelvis. 

The  two  ovaries  are  seldom  entirely  symmetrical  in  position,  one  being 
higher  or  more  anterior  than  the  other  and,  if  the  uterns  is  deflected 
to  one  side  (according  to  His,  to  the  left  side  in  the  proportion  of 
three  to  two),  the  ovary  on  the  opposite  side  is  more  exposed  by  the 
tube  being  somewhat  drawn  away  from  it.  In  the  supine  position  the 
ovary  lies  with  its  long  axis  horizontal.  The  changing  relations  of 
the  contiguous  viscera  also  probably  affect  its  position. 

The  ovary  may  be  displaced  into  Douglas'  sac  or  even  into  the  utero- 
vesical  pouch  ;  it  may  be  found,  especially  in  childhood,  in  an  inguinal 
or  femoral  hernia,  where  it  is  liable  to  strangulation,  and  it  may  become 
fixed  in  its  abnormal  position  by  adhesions.  In  ijregnancy  the  posi- 
tion of  the  ovary  is  normally  altered.  When  enlarged  the  ovaries  may 
he  felt  through  the  vagina,  or  even  better  through  the  rectum.  Their 
position  is  indicated  on  the  surface  by  a  point  about  two  inches  internal 
to  the  anterior  superior  iliac  spine  or  in  a  sagittal  plane  midway  between 
the  latter  spine  and  the  symphysis.  A  frontal  plane  at  the  promontory 
of  the  sacrum  touches  or  lies  just  behind  the  ovaries.  The  position 
of  the  ovary  corresponds  to  the  middle  of  the  upper  margin  of  the 
acetabulum. 

The  ovary  is  held  loosely  in  position  by  the  attachment  of  the 
tuboovarian  ligament  (fimbria  ovarica)  to  its  upper  end  and  of  the 
uteroovarian  ligament  to  its  lower  end,  and  by  being  contained  within 
the  posterior  fold  of  the  broad  ligament  from  which  it  projects 
backward  so  as  to  be  connected  with  it  only  along  the  attached  mar- 
gin. The  ligamentum  infundibulo-pelvicum,  a  fold  of  the  broad  liga- 
ment containing  the  ovarian  vessels,  passes  from  the  side  of  the 
pelvis,  above  and  in  front  of  the  ovary,  to  its  attached  border  where 
the  vessels  enter  the  hilum.  This  "ligament"  helps  to  support  the 
ovary  and  forms  part  of  the  pedicle  in  removal  of  the  ovary  or  ovarian 
tumors. 

Of  the  relations  of  the  ovary  we  have  named  the  most  important, 
the  Fallopian  tube  and  the  ureter.  The  ureter,  with  the  uterine  artery 
in  front  of  it,  lies  behind  the  ovary.  External  to  the  ovary,  in  the 
fossa  ovarica,  are  the  obturator  vessels  and  nerve.  Internal  to  the 
ovary,  in  addition  to  the  tube,  are  coils  of  intestine. 

Structure. — The  ovary  receives  from  the  posterior  layer  of  the  broad 
ligament  an  external  covering,  which  differs  from  the  serous  membrane 
of  the  latter  in  being  covered  by  columnar  epithelium.  Many  of  the 
ovarian  cysts  take  origin  in  this  epithelium.  The  surface  is  smooth 
before  puberty  and  more  and  more  scarred  during  menstrual  activity. 
The  scars  represent  where  ovisacs  have  ruptured  and  the  larger  ones 
in  multiparse  the  position  of  a  true  corpus  luteum  which  forms  when 
pregnancy  occurs.  Slight  extravasation  of  blood  follows  the  rupture 
of  an  ovisac  (or  Graafian  follicle)  but  when  a  vessel  of  unusual  size  is 
ruptured,  or  possibly  when  the  ovary  is  unduly  congested,  a  sudden 
copious  bleeding  may  occur  and  the  blood  collect  in  Douglas'  pouch  as 


PLATE   XLV. 


FIG.  89. 


TIONS    OF 


\  ROUND    LIG*- 

**       '        WENT 


Female  pelvic  viscei-a  from  above.  The  ovary  and 
tube  of  the  left  side  have  been  lifted  out  of  place. 
(Gerrish,  after  Testut. ) 


DEVELOPMENT  OF  THE  OVARV.  387 

a  pelvic  hcematoccle,  which  we  can  then  feel  as  a  doughy  tumor  by  vagi- 
nal or  rectal  examination. 

The  so-called  tunica  albuginea  is  a  thin  layer  and  is  merely  a  con- 
densation of  the  ovarian  stroma.  Within  it  Hes  the  cortex  con- 
taining numberless  Gnuifan  foUiclen  (ovisacs)  in  various  stages  of 
development  and  the  remains  of  some  that  have  burst  at  the  men>trual 
periods.  Some  ovarian  tumors  (cystic)  are  due  to  a  collection  of  tluid 
in  a  dilated  Graafian  follicle  (unilocular)  or  follicles  (multilocular). 
The  ovisacs,  as  they  ripen,  enlarge  and  approach  the  surface,  where 
they  appear  as  large  rounded  projections  when  ready  to  rupture  and 
set  free  the  ovum. 

The  ovary  may  also  be  affected  by  maJIf/nant  nnc  r/rairllis  and  l.v  (hr- 
mold  Gijsfs^  the  latter  due  to  an  island  of  epiblast  abnormallv  included  in 
the  mesoblastic  ovarian  tissue.  Ovarian  tumors,  if  one  side  alone  is 
involved,  are  at  first  unilateral  in  position,  displacing  the  body  of  the 
uterus  to  the  opposite  side,  the  cervix  usually  to  the  same  side.  Later 
they  ascend  into  the  abdomen,  disj)lacing  the  intestine  upward  so  as  to 
cause  dullness  on  percussion,  in  distinction  to  the  tympanitic  note  we 
obtain  in  ascites  from  the  bowel  floating  above  or  in  front  of  the 
fluid. 

The  ve.'^sels  enter  or  emerge  from  the  ovary  at  tlie  hilum,  near  which 
the  ovarian  veins  form  a  large  plexus  in  the  broad  ligament  (pam- 
piniform plexus). 

Development. — The  ovary,  developed  in  the  lumbar  region  like 
the  testis,  is  pulled  down  into  the  pelvis  in  a  similar  manner  by  the 
inguinal  liyrtment  of  the  primitive  kidney.  This  ligament,  attached 
to  the  uterus  and  the  inguinal  region,  rcm(iin.'<  as  the  uieroovdrinn 
ligament  between  the  ovary  and  the  uterus,  and  the  round  ligament 
between  the  uterus  and  the  inguinal  region.  In  hernia  of  tiie 
ovary  the  fibromuscular  utcroovarian  ligament  draws  the  uterus  for- 
ward and  to  the  side  of  the  hernia,  a  fact  that  may  be  useful  in 
diagnosis. 

The  upper  series  of  Wolffian  tubules  may  persist  as  a  small  pedun- 
culated cystic  sac,  the  Jii/dafid  of  Morgagni  (appendix  vesiculosa),  at- 
tached to  the  part  of  the  broad  ligament  forming  the  free  border  of  the 
mesosalpinx  and  adherent  to  the  fimbria  ovarica  or  one  of  the  other 
fimbrine  of  the  tube.  The  parovarium  (organ  of  Rosenmiiller)  is  the 
atrophied  remains  of  the  middle  series  of  the  ^^'olfllan  tubules,  which 
in  the  male  form  the  epididymis.  This  lie.^  above  the  ovary  in  the 
mesosalpinx  and  consists  of  several  vertical  tubes  joining  at  right 
angles  a  horizontal  tube,  a  segment  of  the  Woltlian  duct,  which  lies 
above  them.  The  Wolthan  duct  disapj)ears  elsewhere  as  a  rule,  but 
may  occasionally  persist  as  a  small  canal  in  tiie  broad  ligament  close 
to  the  uterus,  the  duct  of  (lartner,  which  is  lost  in  the  vaginal  wall  or 
may  open  near  the  urinary  meatus.  In  these  fietal  struitures,  esj)e- 
cially  the  parovarium,  develop  the  majority  of  the  unilocular  cysts  of  the 
broad  ligament  [parovarian  ci/sts).  These  generally  c(mtain  a  clear 
fluid  and  may  often  be  cured  by  simple  puncture. 


388  PELVIS  AND  PERINEUM. 

The  Fallopian  Tubes  (Oviducts). 

These  trumpet-shaped  tubes,  about  4  J  inches  long,  are  structurally  con- 
tinuous with  the  uterus  at  its  superior  angles  from  which  they  pass  out- 
ward to  the  sides  of  the  pelvis,  where  they  are  closely  related  and 
connected  with  the  ovaries.  They  lie  between  the  two  layers  of  the 
broad  ligaments,  along  their  upper  free  margins,  so  that  the  serous 
membrane  covers  three  fourths  of  their  circumference  and,  being  re- 
flected off  inferiorly,  forms  the  mesos(djjin.r.  The  lower  fourth  of  their 
circumference  is  in  contact  with  the  subperitoneal  tissue  between  the 
layers  of  the  broad  ligaments.  Thus  a  tuba/  pregnanci/  or  a  fluid  col- 
lection in  the  tube  (hydro-  or  pi/osalpinx)  when  it  rupAures  may  burst 
into  the  peritoneal  cavity,  a  dangerous  course,  or  between  the  layers  ol 
the  broad  ligament.  The  tubes  lie  between  and  slightly  above  the 
round  ligament  in  front  and  the  uteroovarian  ligament  behind. 

Course  and  Size. — At  the  outset  it  must  be  remembered  that  the 
tube,  lying  in  the  free  margin  of  the  broad  ligament  and  connected 
with  two  movable  viscera,  the  uterus  and  ovary,  must  of  itself  be 
freely  movable  and  thus  affected  in  its  position  by  the  conditions  of  the 
neighboring  viscera.  The  narrow  sfraigJd  inner  portion,  or  isthmus 
(3—6  cm.  long),  passes  horizontally  outward  and  slightly  backward 
from  each  superior  angle  of  the  uterus  to  the  uterine  or  lower  end  ot 
the  ovary  at  the  side  of  the  pelvis.  Thence  the  curved  and  dilated 
portion,  or  ampulla  (7—9  cm.  long),  bends  sharply  upward  along  the 
mesial  aspect  of  the  attached  margin  of  the  ovary  to  its  upper  or  tubal 
end,  over  which  it  bends  backward  and  then  downward  along  the  free 
border  and  the  mesial  surface,  upon  which  rests  the  funnel-shaped  fimbri- 
ated extremity,  fringed  by  a  circle  or  circles  of  diverging  fiinbrice  |  to 
-|  inch  long.  Thus  the  ovary  is  more  or  less  hidden  (see  Ovary,  page 
386).  One  fimbria  longer  than  the  rest  (1-1|  inches)  and  attached  to 
the  upper  end  of  the  ovary  (^fimbria  ovarica)  constitutes  the  tuboova- 
rian  ligament. 

The  Fallopian  tube  forms  a  passage  ivay  between  the  uterine  cavity 
(and  thus  the  surface  of  the  body)  and  the  peritoneal  cavity,  whereby 
the  ovum,  when  it  escapes  into  the  latter  by  the  rupture  of  the  ovisac, 
may  reach  the  uterus.  Hence  also  through  this  passage  way  uterine 
or  vaginal  douches  and  microorganisms  may  reach  the  peritoneal 
cavity  and  cause  pelvic  and  perhaps  general  peritonitis. 

The  fiynbrice  of  the  funnel-shaped  outer  end  of  the  ampulla  of  the 
tube  normally  so  embrace  the  ovary  that  they  conduct  the  ovum  into 
the  abdominal  opening  of  the  tube.  When  from  inflammation  these 
fimbriae  become  adherent  together,  or  to  neighboring  parts,  and  close 
the  opening  on  both  sides  the  ova  cannot  escape  out  of  the  abdominal 
cavity  and  sterility  results.  Again,  in  rare  instances  when  the  adapta- 
tion of  the  fimbriae  is  imperfect,  an  ovum,  fecundated  by  spermatozoa 
which  have  passed  through  the  tube,  may  drop  back  and  develop  in 
the  peritoneal  cavity  as  one  form  of  extra-uterine  pregnancy. 

The  mucous  membrane  which  lines  the  tube  is  arranged  in  longi- 
tudinal folds  and   lined   by   a   ciliated  epithelium  whose  movement  is 


PLATE   XLVI 

FIG.  90. 


Sagittal  section  through  the  ovary  and  broad  ligament. 

1.   Broad  ligament.      1^.  Anterior  surface.      1".   Posterior  sur- 
face.    2.   Mesosalpinx.     5.  Fallopian   tube.     6.  Round   ligament. 

7.  Ovary.     1'.  Hilum  of  ovary  with  vessels  entering  the  same. 

8.  Graafian  follicle.  9.  Uterine  artery.  lO.  Uterine  veins.  11. 
Cellular  tissue  at  the  base  of  the  broad  ligament.  12.  Ureter-. 
(Testut.  1 


FIG.  91. 


.RECTAL    PERITONEUM 
ECTO-UTERINE     POUCH 

ANTERIOR  AND  POS- 
TERIOR LAYERS  OF 
BROAD    LIGAMENT 

VESICAL 
PERITONEUM 

VESICO-UTERINE 
POUCH 


VAG1N»^ 

The  cervix  uteri  and  upper  end  of  the  vagina,  showing  their 
relations  to  the  peritoneum.  Diagrammatic.  (Gerrish,  after 
Testut.) 


THE  BROAD  LIGAMEi\TS.  380 

toward  the  uterus,  thus  favoring  the  passage  of  the  ovum.  When 
from  inflammation  extending  from  the  uterus,  i)erhaps  of  gonorrh.i-al 
origin,  the  tube  has  lost  its  epithelium  the  descent  of  the  ovum  is 
hindered  and  the  ascent  of  spermatozoa  is  not,  thus  favoring  the  occur- 
rence of  extra-uterine  pregnancy.  The  lumen  of  the  tube  varies,  being 
about  1  mm.  at  the  uterine  aperture,  |  incii  in  tiie  isthmus,  ^  inch  in 
the  ampulla,  and  ^^^  to  |  inch  at  the  abdominal  ai)erture.  Ciliated 
epithelium  extends  along  the  inner  surface  of  the  fimbriie  and  grad- 
ually merges  into  the  endothelium  of  the  peritoneum  on  their  outer 
surface.  The  fimbriated  extremities  furnish  the  only  instance  where 
serous  and  mucous  membranes  adjoin  one  another. 

As  the  result  of  injianimdiion  the  tube  may  be  dosed,  especiallv  at 
its  narrow  points,  the  two  extremities,  so  that  the  products  of  inflam- 
mation are  pent  up  within  the  tube,  which  becomes  dixtended  to  the 
size  of  the  intestine  {hydro-  or  pyosalpinx,  pus  tube).  In  such  cases 
also  the  peritoneum  on  its  surface  is  apt  to  contract  adhesions  to  neigh- 
boring parts.     The  closure  of  the  lumen  of  the  tubes  also  causes  Htrrilitii. 

A  tube  enhirgcd  by  tubal  pregnancy  or  from  hydro-  or  pyosalpin- 
gitis  may  be  felt  by  vaginal  or  rectal  examination.  They  may  be 
reached  for  operation  (1)  by  the  vaginal  route,  («)  laterally  between  the 
layers  of  the  broad  ligament,  and  therefore  extra-peritoneallv,  {b) 
jx)steriorly  through  Douglas'  pouch,  as  in  vaginal  hysterectomy;  (2) 
through  an  abdominal  incision. 

It  should  be  remembered  in  operations  that  the  fimbriated  extremity 
may  be  in  close  relation  with  the  ureter,  a  matter  of  importance  if 
adhesions  exist. 

The  tubal  blood  supply  is  from  a  branch  of  the  ovarian  artery  run- 
ning along  its  lower  border  in  the  broad  ligament  which  forms  its 
mesosalpinx. 

In  their  development  the  Fallopian  tubes  represent  the  upper  ex- 
tremities or  ununited  parts  of  the  ducts  of  Midler  ;  hence  morpho- 
logically as  well  as  structurally  they  are  continuous  with  the  cornua  of 
the  uterus. 

The  Broad  Ligaments. 

These  ligaments,  also  called  lateral  ligaments  from  their  position 
on  either  side  of  the  uterus,  form  as  it  were  a  common  mesentery  for 
the  uterus  and  its  adnexa,  especially  the  Fallopian  tubes.  They  con- 
sist essentially  of  the  tico  layers  of  peritoneum  which,  after  covering  the 
anterior  and  posterior  surfaces  of  the  uterus  as  described  (p.  381 ),  are 
reflected  from  the  sides  of  the  latter  to  the  sides  and  floor  of  the  jwlvis, 
where  they  become  continuous  with  the  parietal  peritoneum. 

In  addition  to  the  Fallopian  tube,  ovary,  round  ligament  and  fietal 
relics,the  broad  ligament  of  each  side  contains  between  its  folds, the  utero- 
ovarian  ligament,  the  uterine,  ovarian,  and  funicular  vessels,  the  corre- 
sponding lymphatics, the  uterine  plcxusof  nerves, unstriped  muscle  tissue 
continuous  with  the  uterus  mesially,  and  loose  adipose  cellular  tistfuc  con- 
tinuous with  the  subperitoneal  tissue  of  the  pelvis.  In  this  tissue  at 
the  base  of  the  ligament  lies  the  ureter  in  relation  with  tiie  uterine  ves- 


390  PELVIS  AXD  PERINEUM. 

sels  (see  p.  382).  Inflammation  of  this  tissue  [parametritis,  if  near  the 
sides  of  the  uterus)  is  the  commonest  form  of  pelvic  ceHulifis  in  women, 
and  often  results  in  abscess.  It  may  spread  from  an  inflammation  of 
the  small  amount  of  similar  tissue  separating  the  muscular  and  perito- 
neal coats  of  the  uterus  (pjerimetritis)  and  it  may  extend  to  the  similar 
tissue  beneath  the  parietal  peritoneum  of  the  pelvis,  or  pass  over  the 
pelvic  brim  into  the  iliac  fossa  where  it  often  points  just  above  Poupart's 
ligament  (see  p.  275). 

The  muscular  tissue  ensheaths  the  vessels  and  is  of  special  importance 
in  serving  as  a  ."tupport  to  the  uterus  and  helping  to  keep  it  in  place. 
When  the  uterus  enlarges  during  pregnancy  it  fills  the  space  between 
the  folds  of  the  broad  ligaments  so  that  the  latter  nearly  disappear,  to 
reappear  with  the  involution  of  the  uterus  Hence  for  a  time  after 
parturition  they  are  lax  and  offer  but  feeble  resistance  to  uterine  dis- 
placements, a  reason  for  not  allowing  a  woman  to  get  up  too  soon  after 
confinement. 

Each  broad  ligament  represents  a  quadrilateral  plate  which,  with  the 
uterus,  divides  the  pelvis  into  an  anterior  (utero vesical)  and  a  posterior 
(uterorectal)  fossa.  The  inner  or  mesial  border  of  the  broad  ligament 
represents  its  attachment  to  the  sides  of  the  uterus  and  the  upper  end  of 
the  vagina.  In  this  border  the  uterine  vessels  pass  up  along  the  sides 
of  the  uterus.  As  the  posterior  fold  passes  onto  the  posterior  surface 
of  the  upper  end  of  the  vagina  we  can  understand  how  an  incision  in 
the  lateral  wall  of  this  part  of  the  vagina  will  open  into  the  space 
between  the  two  layers  of  the  ligament  at  its  base,  and  how  we  can 
palpate  through  the  vagina  any  tumor  or  swelling  situated  here.  The 
base  or  lower  border  of  the  broad  ligaments  rests  upon  the  floor  of  the 
pelvis,  formed  by  the  levator  ani  and  covered  by  the  rectovesical 
fascia.  The  abundant  areolar  tissue  here  gives  passage  to  the  uterine 
vessels  and  nerves  and  the  ureter,  which  pass  from  behind  and 
externally  forward  and  inward.  Here,  as  well  as  along  its  lateral 
border,  its  layers  become  continuous  with  the  parietal  peritoneum  of 
the  pelvis.  Owing  to  the  slant  of  the  pelvic  cavity  the  anterior  layer 
is  reflected  at  a  higher  level  than  the  posterior,  so  that  the  latter  is 
deeper  or  longer  than  the  former.  It  is  also  more  important  on  account 
of  its  direct  relation  with  the  ovary  and  the  fimbriated  extremity  of 
the  tube. 

Its  lateral  borders  transmit  the  ovarian  vessels  and  the  round  ligaments 
and  meet  the  sides  of  the  pelvis,  lined  by  the  obturator  internus  muscle 
and  fascia.  The  two  layers  are  continuous  along  the  free  upper  border  of 
the  broad  ligament  which  contains  the  Fallopian  tube,  so  that  the  upper 
part  of  the  ligament  forms  the  mesentery  of  the  tube  (^^mesosalpin.v). 
But  the  tube  does  not  extend  to  the  lateral  limits  of  the  broad  ligament. 
The  outer  part  of  the  free  upper  margin  of  the  ligament,  beyond  the 
fimbriated  extremity  of  the  tube,  is  at  a  lower  level  than  the  mesial 
portion  (mesosalpinx)  and  contains  the  ovarian  vessels  as  they  pass  from 
the  sides  of  the  pelvis  to  the  ovary.  It  presents  a  concave  rounded 
margin  and  is  called  the  infundibulo -pelvic  ligament,  since  it  extends 


THE  ROUND  LIGAMENTS.  391 

between  the  infundibuliim  (fimbriated  extremity  of  the  tube)  and  the 
side  of  the  pelvis.  Together  with  a  portion  of  the  broad  liji^anient, 
the  Fallopian  tube  and  the  utero-ovarian  ligament  it  constitutes  the 
jjedicle  of  an  ovarian  tumor. 

The  upper  part  of  the  broad  ligament  which  forms  the  memsalpinx 
is  thin,  translucent,  devoid  of  muscular  tissue  and  rontfiinn  the  fcjetal 
relics  and  the  tubo-ovarian  vessels.  Projecting  from  and  attached  to 
the  posterior  layer  is  the  ovary.  More  mesially  the  recto-uterine  or 
posterior  ligaments  of  the  uterus  are  continuous  with  this  same  laver. 
Betircen  the  folds  of  the  broad  ligament  um\ocu\nr  ci/stic  tumor-s  (usually 
originating  from  f(etal  relics),  hematocele,  abscess  and  tumors  are  found, 
of  which  the  cystic  tumors  are  perhaps  the  most  common.  These  may 
all  be  palpated  through  the  vagina  and  reached  for  operation  by 
means  of  a  vaginal  or  abdominal  incision.  Unlike  many  ovarian 
tumors  they  are  commonly  sessile  and  rarely,  if  ever,  pedunculated. 
We  are  accustomed  to  think  of  the  broad  ligaments  as  vertical,  and  as 
such  to  describe  them,  but  when  we  consider  the  normal  anteflexed 
position  of  the  uterus  we  find  that  the  greater  part,  except  the  base, 
of  the  uterine  end  of  the  ligament  is  more  horizontal  than  vertical. 

The  Round  Ligaments. 
These  two  rounded  cords  of  unstriped  muscle,  fibrous  and  elastic 
tissue,  about  five  inches  in  length,  commence  at  the  upper  angles  of  the 
uterus  just  below  and  in  front  of  the  Fallo})ian  tubes,  where  thev  are 
continuous  with  the  superficial  uterine  fibers.  P^ach  passe.s  at  first 
downward  and  outward  toward  the  base  of  the  broad  ligament;  then 
nearly  horizontally  outward  near  the  base  of  the  ligament  and  beneath 
its  anterior  layer,  in  front  of  the  ureter  and  the  uterine  vessels;  thence 
upward,  outward  and  forward  over  the  pelvic  brim  and  the  lower  end 
of  the  iliac  fossa  to  the  internal  abdominal  ring.  In  the  latter  part  of 
its  course  xicorrcjiponds  to  that  of  the  vas  deferens  and  crosses,  like  the 
latter,  the  obturator  and  external  iliac  vessels  and  the  unobliteratcd 
portion  of  the  hypogastric  artery  (/.  e.,  superior  vesical  artery),  and 
finally  loops  around  the  outer  side  of  the  curve  of  the  deep  ej)igastric 
artery  to  enter  the  inguinal  canal.  In  this  part  of  its  course  also  it 
not  infrequently  projects  so  far  forward  as  to  form  a  kind  of  short 
mesentery.  In  passing  through  the  inguinal  canal  it  receives  a  cover- 
ing from  the  layers  of  the  abdominal  wall  like  the  spermatic  con),  but 
the  striped  fibers  derived  from  the  cremaster  are  mostly  attached  to 
the  pillars  of  the  ring  and  the  pubic  spine.  It  may  be  accompanied 
by  a  process  of  peritoneum,  the  canal  of  Nuck,  which  correspontls  to 
the  processus  vaginalis  in  the  male  and  oi-curs  as  a  sac-like  jxnich 
above  and  in  front  of  the  mund  ligament,  not  as  a  hollow  tube 
around  it,  as  is  sometimes  described.  This  serous  pouch  is  constant  in 
the  fojtus,  occurs  in  children  in  twenty  per  cent,  of  cases  (Zucker- 
kandl),  and  in  isolated  cases  may  persist  even  to  adult  life.  But  usu- 
ally it  is  only  represented  by  a  funnel-shaped  depression  at  the  internal 
ring. 


392  PELVIS  AND  PERINEUM. 

When  present  it  predisposes  to  inguinal  hernia,  or  it  may  form  the 
sac  of  a  hydrocele.  After  leaving  the  external  ring,  which  in  the 
female  is  smaller  than  in  the  male  and  lies  just  external  to  and  a  little 
above  the  pubic  spine,  the  round  ligament  expands  fan-like  to  be  at- 
tached to  the  connective  tissue  of  the  labium  majus  and  the  periosteum 
over  the  pubic  spine. 

When  the  uterus  is  in  its  typical  position  the  round  ligaments  are 
not  taut,  but  only  when  there  is  bachvard  displacement  or  a  prolapse, 
hence  they  play  but  a  secondary  role  in  supporting  the  uterus. 

For  the  displacements  just  named  Alexander's  operation  of  shorten- 
ing the  ligaments,  and  thereby  pulling  the  uterus  forward  and,  if  pro- 
lapsed, upward,  has  been  often  performed.  The  incision  is  like  that 
for  inguinal  hernia. 

Sometimes  there  is  difficulty  in  finding  the  ligament  and  for  this  pur- 
pose the  external  ring  is  exposed  and  the  tissues  below  and  internal  to 
it  are  hooked  up  and  pulled  upon,  or  the  canal  is  slit  up  for  a  distance 
and  the  contents  of  the  canal  similarly  dealt  with.  We  may  pull  down 
and  shorten  the  ligament  by  as  much  as  four  inches  in  some  cases. 
After  pulling  down  the  cord  for  a  certain  distance  a  pouch  of  peritoneum 
is  apt  to  appear  at  the  external  ring.  This  may  represent  the  canal  of 
Nuck,  or  more  often  a  new  pouch  pulled  down  from  the  peritoneum  at 
the  internal  ring.  Such  a  pouch  occupying  the  canal  naturally  pre- 
disposes to  hernia  and  the  latter  has  not  infrequently  followed  such 
operations. 

The  round  ligament  is  stronger  than  one  would  suppose  and  bears  a 
very  considerable  traction  (.5-.6  kgr.,  according  to  different  observers). 
In  pregnancy  it  becomes  four  times  as  stout  as  in  the  non-pregnant 
state.  Contraction  or  preternatural  shortness  of  the  ligaments  is  said 
to  be  a  cause  of  anterior  displacement  of  the  uterus. 

Its  artery,  the  funicular,  is  derived  like  that  of  the  vas  deferens  from 
the  superior  vesical  (/.  e.,  hypogastric),  as  the  ligament  crosses  the 
latter.  It  anastomoses  with  the  uterine  and  ovarian  at  the  uterine  end 
and  with  the  external  pudic  in  the  labium. 

The  Vagina. 

This  musculo-membranous  passage  tcay  between  the  vestibule  and 
the  uterus  is  directed  upward  and  backward  in  the  line  of  the  pelvic 
outlet  below  and  the  pelvic  axis  above.  It  forms  an  angle  of  25  to  35 
degrees  with  the  long  axis  of  the  body  and  of  65  to  75  degrees  with 
the  horizon,  but  these  measurements  vary  with  the  pelvic  inclination 
of  the  individual  and  with  the  condition  of  the  bladder  and  rectum. 
Nearly  half  of  it  lies  below  the  plane  of  the  pelvic  outlet. 

Its  icalls,  ordinarily  in  cotifacf,  present  on  transverse  section  an  H- 
shaped  fissure.  Its  anterior  wall  measures  2^  to  3  inches  in  length, 
the  posterior  nearly  3^  inches.  In  the  lateral  dimensions  it  is  extra- 
ordinarily dilatable,  admitting  the  passage  of  the  foetus  at  birth.  The 
anterior  wall  is  in  close  relation  with  the  urethra  below  and  the  bladder 
above.     The  trigonum  vesic(e  and  the  base  of  the  bladder  just  above  it 


THE    VAGI^^A.  393 

are  connected  with  the  vaginal  wall  by  connective  tissue  continuous 
with  the  subperitoneal  tissue  between  tlie  cervix  and  the  bladder.  So 
close  is  this  connection,  especially  with  tiie  trigonuni,  that  when  the 
vagina  is  everted  like  a  glove-finger  in  pro/apse  of  the  uterus  the  bladder 
wall  is  drawn  down  with  it  as  a  j)ouch  projecting  into  the  vagina 
{ci/s(ocek').  In  complete  prolapse  the  urcthm,  the  lower  two  thirds  of 
which  are  most  infiniafc/i/  comiccfcd  ivifh  the  raf/ina/  my///,  is  also  in- 
verted, so  that  from  the  meatus  its  direction  is  downward  and  back- 
ward. When  the  support  afforded  by  the  perineum  is  weakened  by 
its  rupture  acystocele  may  project  into  the  vagina  without  uterine  pro- 
lapse, but,  according  to  Sims,  a  cystocele  always  precedes  complete 
prolapse  of  the  uterus. 

Owing  to  prolonged  pressure  between  the  fwtal  head  and  the  pubic- 
bones  during  a  tedious  labor,  the  vesicovaginal  septum  may  slough  and 
give  rise  to  a  vesicovaginal  jiHhda.  Similar  fistuhemay  also  occur  from 
a  like  cause  between  the  urethra  and  vagina  or  between  the  idadder  and 
cervical  canal  or  these  three  forms  of  fistula  may  be  combined  in  one. 

The  trigonum  vesicce  \s  faintly  indicated  on  the  anterior  vaginal  trail  as 
follows:  the  base  by  a  transverse  fold  of  mucous  membrane,  slight Iv 
convex  inferiorly,  about  2}  to  8  cm.  below  the  external  os  uteri,  and 
the  sides  by  two  folds  which  diverge  from  the  upper  end  of  the  ante- 
rior columna  rugarum.  Pawlik  used  these  markings  in  caiheterizing 
the  ureters,  whose  openings  are  at  the  upper  angles  of  the  trigonum, 
but  we  have  a  surer  way  in  Kelly's  method  through  a  urethral  specu- 
lum. Above  the  base  of  the  trigonum  the  ureters  pass  upward  and 
outward  diverging  somewhat  so  as  to  reach  the  upper  end  of  the  lateral 
vaginal  walls,  where  they  occupy  the  triangular  space  between  the 
levator  ani  muscle  and  the  vagina.  Calculi  lodged  in  the  lower  inch 
or  two  of  the  ureters  may  therefore  be  felt  and  removed  through  the 
upper  part  of  the  vagina. 

The  lateral  walls  of  the  vagina  are  in  contact  above  with  the  base  of 
the  broad  liganients  and  their  contents,  including  the  uterine  vessels. 
Hence  we  can  here  palpate  or  expose  these  parts  by  incision  (see  Broad 
Ligaments,  p.  390).  In  its  lower  two  thirds  the  lateral  vaginal  wall 
is  in  contact  with  the  rectovesical  fascia  and  the  antero-internal  border 
of  the  levator  ani  muscles  as  well  as  with  the  vaginal  vessels. 

The  posterior  vaginal  wall  is  in  contact  with  the  rectum  from  which 
its  up])cr  fourth  ( ','  inch  or  so)  is  separated  hi/  the  peritoneal  pouch  of 
Douglas,  its  middle  portion  by  areolar  tissue,  continuous  with  the  sub- 
peritoneal connective  tissue,  and  its  lower  end  by  the  perineal  bodif. 
Hence  we  can  paljjate  through  the  vagina  the  contods  of  the  lower  end 
of  Douglas'  pouc/i,  whether  this  be  the  coils  of  intestine,  normally 
present,  or  a  retrouterine  hicniatocele,  a  retroflexed  uterus,  a  uterine 
fibroid,  or  a  displaced  and  perhaps  cystic  ovary  or  tube.  Through 
the  upper  end  of  the  posterior  vaginal  wall  we  may  reach  by  incision 
the  peritoncid  cavity  in  Douglas'  pouch  and  through  this  incision  break 
up  adhesions  l)ehind  the  uterus  or  reach  its  adnexa.  The  peritoneal 
cavity  may  also  be  opened  by  traumatism  inflicted  tliroiigh  thc^  vagina, 


394  PELVIS  AND  PERINEUM. 

and  through  such  an  opening  intestinal  coils  may  protrude.  Rarely 
the  intestinal  coils  occupying  Douglas'  pouch  may  protrude  from 
above  and  behind  into  the  vagina  as  an  enterocele,  or  lower  down  the 
rectum  may  form  a  similar  pouch  or  redocele.  Such  a  pouch  does  not 
necessarily  accompany  a  prolapse  of  the  uterus  with  eversion  of  the 
vagina,  for  the  latter  is  more  loosely  connected  ivith  the  rectum  than  with 
the  bladder  and  may  not  pull  it  down.  Similarly  in  prolapse  of  the 
rectum  the  vagina  is  not  necessarily  pulled  down. 

Although  the  rectovaginal  septum  does  not  suffer  from  pressure  as 
does  the  vesicovaginal,  yet  it  may  be  torn  through  even  to  a  high  level 
at  childbirth.  If  such  a  complete  rupture  is  not  healed  throughout  it 
may  leave  a  rectovaginal  fistuUi . 

The  upper  end  is  the  largest  part  of  the  vagina.  Its  angle  of  reflec- 
tion onto  the  cervix  is  known  as  the  fornix  and  should  be  supple 
when  normal.  Into  this  upper  end  the  intravaginal  portion  of  the 
cervix  projects  at  an  angle.  (See  Uterus,  p.  381.)  The  line  of  vaginal 
attachment  is  oblique  from  behind  forward  and  downward,  making  the 
posterior  vaginal  fornix  much  deeper  than  the  anterior  and  the  pos- 
terior vaginal  wall  longer  than  the  anterior,  so  that  it  may  sometimes 
be  difficult  to  reach  the  limit  of  the  posterior  fornix  with  an  examining 
finger  of  moderate  length. 

The  lower  end  is  the  narrowest  part  and  may  be  still  further  nar- 
rowed by  the  engorgement  of  the  bulbs  of  the  vestibule,  which  flank  it  on 
either  side,  and  by  the  contraction  of  the  constrictor  or  sphincter  vagince 
and  perhaps  also  of  the  levatores  ani.  The  spasmodic  contraction  of 
the  constrictor  vaginse  known  as  vaginismus  may  interfere  with  coitus. 
It  may  require  surgical  treatment,  but  the  surrounding  parts  should 
first  be  carefully  inspected  to  discover  if  possible  some  cause  of  reflex 
irritation.  As  the  vagina  near  its  lower  end  pierces  the  triangular 
ligament,  this  part  of  the  canal  is  also  the  most  resistant  to  dilatation. 
The  lower  end,  orijicium  or  introitus  vagina',  is  partly  shut  off  from  the 
vestibule  in  the  virgin  by  an  imperfect  septum,  the  hymen.  This  mem- 
branous fold  varies  much  in  shape,  but  it  is  usually  crescentic  and 
attached  behind  and  laterally,  having  an  opening  in  front,  though  it 
may  form  a  complete  septum  with  one,  two  or  several  small  openings 
or,  occasionally,  with  no  opening  {imperforate  hymen).  The  latter  con- 
dition causes  a  damming  back  of  the  menstrual  flow  which  fails  to 
appear  and,  unless  relieved,  distends  the  vagina,  the  uterine  canal  and 
even  the  tubes,  and  hence  calls  for  surgical  relief.  Although  the 
hymen  is  usually  ruptured  by  the  first  coitus  it  may  not  be  until  par- 
turition, hence  it  is  not  a  proof  of  virginity  nor  is  its  absence  incom- 
patible with  virginity.  After  parturition  remains  of  the  hymen  ap- 
pear as  rounded  elevations  [caruncuke  myrtiformes)  around  the  orificium 
vaginae. 

As  to  structure  the  very  elastic  vaginal  mucosa,  lined  by  stratified 
epithelium,  is  destitute  of  glands,  hence  vaginal  discharge  is  of  the 
nature  of  a  transudation.  Beneath  the  mucosa  is  a  rich  venous  plexus 
which  may  be  regarded  as  erexitile  tissue  and  may  become  vaj-lcose  and 


THE  FEMALE    URETHRA. 


395 


form  a  pile-like  tumor  near  the  external  orifice.  In  infancy  and 
childhood  the  vagina  is  often  relatively  long,  corresponding  to  the  high 
position  of  the  pelvic  viscera  ;  in  old  (ujc  it  undergf>es  atrophy  and 
sometimes  partial  closure.  Congmitnlly  it  may  be  more  or  less  com- 
pletely divided  by  a  vertical  septum  into  lateral  halves,  usually  con- 
nected with  the  halves  of  a  bifid  uterus.  It  may  also  i)e  verv  !-mall 
and  rudimentary  or  even  \vantiug.  In  the  latter  conditions  other 
parts  of  the  genital  system,  uterus  and  ovaries,  are  likely  t*t  be  rudi- 
mentary or  wanting. 

Fig.  92. 


DORSAL   VEIN 
OF    CLITORIS 


PREPUCE    OF, 

CLITORIS 

GLANS    CLI-' 

TORIOIS 


Sagittal  section  of  the  vagiDa  and  neighboring  parts.    (Gebbisii,  after  Tksti't.  ) 

The  Female  Urethra. 

This  reprexenfs  the  prostatic  find  membranouji  ]>ortiontt  of  the  male 
urethra  and,  like  the  latter  portion,  passes  through  the  two  layers  of  the 
rather  indistinct  triangular  ligament  and  the  striped  muscular  fibers 
representing  the  compressor  urethrre  muscle  (deep  transversus  perinei) 
and  possil)ly  the  prostatic  fibers  also.  The  strijicd  Jihci'-'^  surrouud  the 
urethra  as  a  sphincter  in  its  upper  1  cm.  only,  where  it  is  conuected  to 
the  vagina  by  loose  connective  tissue ;  in  the  lower  part  of  the  urethra, 
where  the  urethral  and  vaginal  walls  blend  to  form  the  urethrovaginal 
septum  (1  cm.  thick  above),  these  fibers  occur  in  front  only.  Circular 
unstriped  fihcr.^  around  the  vesica/  end  form  a  |)o\verful  sj>hincfer.  As 
may  be  ]>roved  by  distension  of  the  bladder  in  the  cadaver,  no  muscu- 
lar action  of  the  sphincters  is  necessary  to  retain  urine,  provided  there 
is  no  vis  a  tergo  througli  abdominal  pressure  or  the  contraction  of 
the  bladder. 

The  urefhrn  may  be  felt  between  the  anterior  vaginal  wall  and  the 
pubes  like  a  round  cord.     The  female  urethra  incasurcfii  1|^  to  1.^  inches 


396  PELVIS  AND  PERINEUM. 

in  length.  In  the  erect  position  it  is  directed  downward  and  slightly- 
forward,  nearly  parallel  with  the  vagina  though  inclining  slightly  more 
forward  below.  Hence  its  lower  end  is  further  from  the  vagina  than 
the  upper  end.  It  is  slightly  convex  backward  yet  not  enough  to  inter- 
fere in  any  way  with  the  passage  of  a  straight  catheter.  Its  exit  from 
the  bladder  is  a  little  below  and  an  inch  behind  the  middle  of  the  sym- 
physis. It  passes  f  to  1^  of  an  inch  below  the  subpubic  arch  and  its  external 
meatus,  usually  a.  sagittal  fiasure,  is  found  near  the  base  of  the  vestibule 
on  a  papilla  one  inch  behind  the  clitoris.  It  is  possible  after  practice 
to  pass  a  catheter  without  exposure  of  the  parts  by  means  of  the  latter 
measurement,  or  better  by  means  of  a  tubercle  just  behind  the  meatus 
at  the  lower  end  of  the  anterior  columna  rugarum  of  the  vagina.  In 
children  and  when  the  parts  are  swollen,  as  after  a  difficult  labor,  the 
meatus  is  relatively  far  back  and  difficult  to  find. 

The  mecdus  is  the  narrowest  part  of  the  canal,  which  averages  7  to- 
8  mm.  in  diameter,  but  it  is  extremely  dilatable  as  it  is  not  surrounded 
by  dense  resisting  structures  as  in  the  male.  Thus  it  may  be  gradu- 
ally dilated  under  an  ansesthetic  so  as  to  allow  the  removal  of  small 
calculi  or  foreign  bodies,  and  the  introduction  of  the  finger  for  explora- 
tion or  of  the  cystoscope  for  examination  or  ureteral  catheterization. 
The  resulting  jxiralysis,  if  it  occurs,  quickly  disappears  unless  the 
dilatation  has  been  too  great  and  too  abrupt,  when  it  may  persist,  as 
reports  of  cases  show.  In  cases  of  imperforate  hymen  and  narrow- 
ness or  absence  of  the  vagina  the  urethra  has  even  become  the  channel 
of  sexual  intercourse. 

In  the  submuGosa  is  a  cavernous  venous  plexus  which  gives  the  mucosa 
a  darkish  hue  during  life  and  may  become  varicose  and  form  a  pile-like 
tumor  near  the  meatus.  Small  vascular  tumors  (papillary  angiomata) 
may  spring  from  the  mucous  membrane  at  or  near  the  meatus,  espe- 
cially in  its  posterior  segment.  These  "  urethral  caruncles "  bleed 
readily  and  are  highly  sensitive  and  sometimes  very  painful,  so  as  to  give 
rise  to  marked  local  and  general  symptoms  and  to  demand  removal. 

Since  the  female  urethra  is  a  short  wide  tube  which  serves  the  pur- 
pose of  a  urethra  only,  inflarnmcdion  is  less  common,  less  severe  and 
easier  to  treat  than  in  the  male,  and  the  resulting  stricture  is  cor- 
respondingly less  common  and  less  complete  and  often  requires  no 
treatment. 


THE  BULBI  VESTIBULI  AND    VULVOVAGINAL  GLANDS.    397 

EXTERNAL  GENITALS. 

A.     FEMALE  EXTERNAL    GENITALS. 

The  vulva  i.s  really  a  deJf-Uhe  apace  between  the  rima  pudendi  (the 
fissure  Ix-twcen  the  two  labia  majoraj  inferiorly,  and  the  hymen  or  its 
remains  superiorly.  It  includes  all  the  other  external  genitals  in  the 
female.  The  two  labia  majora  repretient  the  two  lateral  halves  of  the 
scrotum  in  the  male  and,  like  it,  are  compourd  of  .v/:///  enclosing  an  im- 
j)erfectly  developed  (hnios,  and  are  subject  to  the  same  pfifholof/lral 
coiifJition.s.  They  are  the  usual  situation  of  elephantiasis  in  the  female, 
are  greatly  swollen  in  cases  of  oedema  and  may  contain  large  extrav- 
asations of  blood  (pudendal  htematocele)  after  injury.  They  contain 
a  considerable  amount  of  fat,  with  whose  fibrous  capsule  and  partitions 
the  round  ligament  is  connected.  Inf/uinal  Jicrnun  (sometimes  contain- 
ing the  ovaryj  may  descend  into  them  anteriorly,  pudciidal  lierniir., 
which  escape  between  the  vagina  and  the  pubic  ramus  more  posteriorly. 
Cystic  collections,  probably  in  the  unclosed  canal  of  Xuck  and  known 
as  ^^  hydrocele  in  the  female,"  may  also  occur  in  the  labia  majora. 

Their  point  of  meeting  posteriorly,  the  posterior  rommi^mire  or  Jour- 
<jhette,  is  an  inch  or  more  in  front  of  the  anus  and  limits  the  base  of  the 
perineal  body  anteriorly.  The  fourchette  is  often  torn  in  parturition 
and  i>  the  common  seat  of  chancres  in  the  female. 

The  labia  minora  or  nymphae  contain  much  vascular  tissue  and 
are  not  infrequently  redundant,  projecting  below  the  vulva,  es|>ecially 
in  certain  races  (/.  e.,  Hottentots,  etc.).  On  approaching  the  median 
line  anteriorly  they  bifurcate  and  their  branches  unite  from  side  to  side 
to  form  the  prcrpnfinin  and  the  frenuluni  of  the  clitoris.  Extravagant 
imj)ortance  has  been  attached  by  some  to  the  adhesion  of  this  prepuce 
to  the  clitoris  as  a  cause  of  various  symptoms. 

The  bulbi  vestibuli,  two  pyriform  masses  of  erectile  tissue  corres|X)nd- 
ing  to  the  lateral  halves  of  the  bulbs  of  the  male  urethra,  lie  on  cither 
side  of  the  orifice  of  the  vagina  and  extend  thence  on  either  side  of  the 
vestibule,  beneath  its  mucous  membrane,  to  a  point  below  the  clitoris, 
where  the  two  connect.  Rupture  of  the  bulb  may  occur  from  injurj', 
especially  during  pregnancy  when  they  are  enlarged,  and  results  in  the 
formation  of  a  large  hjematoma  (pudenda/  hnnudocele). 

Behind  the  bulbi  vestibuli  and  on  either  side  of  the  posterior  half 
of  the  vaginal  orifice  lie  the  two  vulvovaginal  glands  {the  (/lundx  of 
Bartholin),  which  probably  represent  Cowper's  glands  in  the  male. 
The  diuis,  three  rpiarters  of  an  inch  long,  opi  n  just  outside  of  the  vaginal 
orifice  and  opposite  its  center,  where  the  opening  may  often  be  seen  as  a 
small  red  depression  on  everting  tiie  nympha?  and  pressing  the  hymen 
inward.  The  r/lands  are  one  third  to  one  half  inch  long,  lie  beneatii 
the  superficial  perineal  fascia  and,  like  the  bulbi  vestibuli,  are  covered 
externallv  bv  the  sj)hincter  vagimo  muscle.  The  duct  and  gland  are 
liable  to  i)iflanimation  and  suppuration,  often  of  gonorrlneal  origin. 
The  resulting  vidvovaginal   abnceHS  is  felt   in  the  base  of  one  of  the 


398 


PELVIS  AND  PERINEUM. 


labia  majora  and  causes  oedema  there.  Cystic  dilatation  of  the  duct  is 
not  infrequent.  These  glands  atrophy  after  the  menopause  if  not  be- 
fore. In  general  the  vessels  and  nerves  of  the  external  genitals  corre- 
pond  to  those  of  the  homologous  parts  in  the  male ;  thus  the  lymphatics 
enter  the  inguinal  nodes. 

B.  THE  MALE  URETHRA  AND  EXTERNAL  GENITALS. 

The  Male  Urethra. 

The  urethra  is  to  be  regarded  as  a  dosed  valve  whose  walls  are  usu- 
ally in  contact.      It  is  a  camtl  only  when  open  for  the  passage  of  urine, 

semen  or  instruments. 

Divisions. — In  its  passage  from 
the  bladder  at  the  vesical  outlet,  or 
internal  meatus,  to  the  external  mea- 
tus it  is  divided  in  various  ways  ac- 
cording to  (1)  the  parts  through  which 
it  passes  (prostatic,  membranous, 
spongy,  etc.),  (2)  its  fixity  and  mo- 
bility, (3)  its  direction  (curved  or 
straight),  (4)  its  pathological  and 
therapeutic  peculiarities  (anterior  and 
posterior  urethra). 

The  prostatic  urethra,  1  to  1^ 
inches  long,  is  spindle-sAa^jcr/.  Its 
upper  narrowed  end,  the  vesical  out- 
let or  internal  meatus,  is  formed  by 
the  annulus  urethralis  (see  p.  369). 
The  latter  is  as  a  rule  quite  dilatable 
but  may  become  thickened  or  more 
resistant  as  the  result  of  spasmodic 
action  during  micturition  in  gouty 
subjects  or  in  those  with  chronic 
urethral  trouble.  In  such  cases  the 
condition  may  be  relieved  by  stretch- 
ing, with  or  without  a  slight  incision. 
If  in  such  cases  the  prostatic  sinus 
is  deep  the  beak  of  the  catheter  or 
sound  may  impinge  on  its  posterior 
wall,  under  the  back  of  the  annulus, 
and  thus  enter  the  bladder  with  diffi- 
culty if  at  all. 

The  central  dilated  part  of  the  pros- 
tatic urethra  presents  an  inverted  U on 
cross  section,  owing  to  the  median  pro- 
(upperT:Ifri^r'"(GK^Kr.'^aft«T.sxuT:r^  f^om  behind  of  the  verumon- 

tanum.  This  contains  erectile  tissue  and 
may  serve  to  close  the  upper  end  of  the  urethra  and  prevent  the  passage 


THE  MEMBRANOUS   URETHRA.  399 

of  semen  back  into  the  bladder.  On  its  summit  in  the  median  line  is 
the  fair  sized  opening  of  the  sinus  pocularis,  or  u(eruf<  ludwidinux,  the 
homologue  of  the  uterus.  This  blind  sinus  /j/z/.s  upward  and  backward 
for  one  fourth  to  one  half  of  an  inch  beneath  the  '*  middle  lobe."  On 
either  side  of  it  run  the  rjdcn/dfori/  ducf.s,  whose  slit-like  openings  are  on 
either  side  of  (sometimes  within)  that  of  the  sinus.  In  the  two  depres- 
sions or  prostatic  sinuses,  one  on  either  side  of  the  verumontanum,  open 
the  (lucf.s  of  (lie  (/Idiul.s  of  f/ie  prostate,  of  which  two  are  larger  and  more 
noticeable.  The  tip  of  a  sound  may  lodge  in  the  prostatic  sinuses, 
especially  in  cases  of  ])rostatic  enlargement.  To  avoid  this  tiic  Ix-ak  of 
a  "prostatic  catheter"  is  longer  and  curved  further  forward  and  the 
flexible  catheters  are  made  with  the  tip  bent  up  (Mercier  catheter).  The 
tip  of  a  small  sound  or  bougie  may  also  lodge  in  the  sinus  pocularis  un- 
less it  is  made  to  hug  the  ni)per  wall.  On  account  of  the  various  open- 
ings into  the  prostatic  urethra  we  can  understand  how  an  inHtuinnd.tiou 
of  this  part  may  extend  (1)  into  the  bladder  and  thence  to  the  ureters 
and  kidneys,  (2)  into  the  ejaculatory  ducts  and  thence  to  the  seminal 
vesicles  or  along  the  vas  deferens  to  the  epididymis,  etc.,  or  (3)  into 
the  substance  of  the  prostate. 

In  the  erect  position  the  course  of  the  prostatic  uretlira  is  nearly 
vertical  with  a  slight  concavity  forward.  It  runs  in  front  of  the  mid- 
dle of  the  upper  two  thirds  and  about  the  middle  of  the  lower  one 
third  of  the  gland,  though  cases  have  been  observed  when  it  has 
merely  occupied  a  groove  on  its  anterior  surface.  The  prostatic  por- 
tion is  not  only  of  large  caliber  but  also  very  dilatable,  readily  admitting 
the  passage  of  the  finger  in  operations  on  the  urethra  or  l)laddcr. 
Stricture  is  unknown  in  this  part  though  congenital  folds  and  pock- 
ets may  occur  here  and  interfere  with  micturition.  The  lower  half  of 
the  prostatic  urethra  may  be  incised  in  the  median  line  without  injur- 
ing other  structures.  Median  incisions  in  the  upper  half  must  be  in 
the  exact  median  line  to  avoid  the  ejaculatory  ducts. 

The  membranous  portion,  or  that  lying  between  the  two  layers  of 
the  triangular  ligament  is  directed  obliquely  downwards  and  forwards 
and  forms  the  beginning  of  the  subpubic  curve.  It  is,  next  to  the 
external  meatus,  the  narrowest  segment  and  measures  about  half  an 
inch  in  Icnr/t/i,  though  the  floor  is  said  by  some  to  measure  less  than  the 
roof  owing  to  the  projection  backwards  of  the  bulb  along  the  floor.  It 
is  surrounded  by  the  compressor  urethra^,  muscle  which  forms  (1)  the 
voluntary  sphincter,  (2)  the  dividing  line  between  the  anterior  and 
posterior  portions  of  the  urethra,  and  (3)  the  cause  of  the  so-called 
spasmodic  strictures.  Close  behind  it  lies  the  bend  in  the  anterior 
wall  of  the  rectum  between  the  anal  and  pelvic  jnirtions.  At  this 
point  an  instrument  can  be  felt  within  or  guided  into  the  membranous 
urethra,  or  the  false  passage  of  an  instrument  may  be  felt  by  the  linger 
in  the  rectum.  Beneath  and  on  either  side  lie  the  btdbourethral 
glands  {('oirper's  (/lands)  the  homologue  of  the  glands  ol"  Bartholin  in 
the  female.  Enclosed  by  the  compressor  urethra^  muscle  and  resting 
on  the  upper  surface  of  the  superficial  layer  of  the  triangular  ligament, 


400  PELVIS  A  SB  PERINEUM. 

one  fifth  of  an  inch  apart,  these  glands  thus  lie  above  and  behind  the 
bulb.  The  formation  of  cyds  or  «6.spr.s-,s  may  occur  in  them,  the  latter 
by  extension  of  gonorrhceal  inflammation  from  the  bulbous  urethra, 
into  the  floor  of  which  their  ducts  (|  to  1  inch  long)  open.  They 
atrophy  as  age  advances. 

The  spongy  portion,  5 J  inches  in  lenr/th,  includes  several  subdivi- 
sions. The  bulbous  portion,  about  an  inch  in  length,  is  the  most  pos- 
terior. Immediately  in  front  of  the  triangular  ligament  the  bulb  at  first 
covers  only  the  floor  and  then  gradually  the  sides,  while  the  front  of  the 
urethra  is  only  covered  by  spongy  tissue  ^  to  -|  of  an  inch  lower  down, 
so  that  some  authors  call  the  portion  not  covered  by  the  bulb  the  prse- 
diaphragmatic  or  pi-idrigonal  portion.  The  front  wall  of  the  latter 
portion  is  thinner  than  elsewhere.  Along  the  floor  of  the  bulbous  por- 
tion the  urethra  is  much  dilated  and  this  dilatation  (fossa  bulbi)  passes 
suddenly,  not  by  a  gradual  narrowing,  into  the  narrow  and  firmly  fixed 
membranous  portion  at  the  point  where  the  latter  pierces  the  firm 
anterior  layer  of  the  triangular  ligament.  This  is  the  critical  point  in 
the  passage  of  instruments,  for  if  the  instrument  is  allowed  to  follow 
the  floor  it  sinks  into  the  dilatation  of  the  bulb  below  the  level  of  the 
membranous  portion  and  then  impinges  on  the  triangular  ligament,  or 
if  pressed  too  closely  against  the  thin  dilatable  anterior  wall  a  like  re- 
sult may  happen.  To  enter  the  narrow  opening  of  the  membranous 
urethra  (*^  neck  of  the  bulb  "  as  the  French  call  it)  the  sound  should  be 
kept  along  the  roof  of  the  urethra  and  as  large  an  instrument  as  will 
pass  should  be  used,  for  it  is  less  likely  to  catch.  We  have  seen  that 
hugging  the  roof  is  also  the  rule  in  passing  the  prostatic  portion  to 
avoid  catching  in  the  sinuses  and  the  annulus. 

The  bulbous  portion  continues  the  subpubic  curve,  commenced  in  the 
membranous  portion,  and  in  the  erect  position  it  forms  the  most  dependent 
part  of  the  fixed  portion  of  the  urethra.  Hence  the  products  of  inflam- 
mation naturally  gravitate  here  and,  as  the  parts  are  bathed  in  pus, 
chronic  inflammation  is  apt  to  linger  here  and  its  results  are  seen  in 
the  common  occurrence  of  stricture.  The  chronic  inflammation,  or  gleet, 
alters  the  lining  mucosa  so  that  plastic  material  is  deposited  beneath  it 
to  prevent  the  soaking  of  urine  into  the  surrounding  tissues.  The 
natural  contraction  of  this  plastic  exudate  narrows  the  lumen  and  so 
results  in  stricture  and  this  keeps  up  the  irritation  and  the  discharge, 
which  is  only  cured  by  the  cure  of  the  stricture.  The  bulb  is  covered 
externally  by  the  accelerator  urinae  muscle. 

In  front  of  the  bulb  the  urethra  continues  in  a  fixed  position,  nearly 
horizontally,  but  with  a  slight  upward  inclination,  to  a  point  beneath  the 
suspensory  ligament.  In  front  of  this  ligament  the  urethra  is  movable 
with  the  penis.  The  ctdiber  of  the  spongy  urethra  is  fairly  uniform 
between  the  bulb  and  the  fossa  navicularis,  the  dilatation  in  the 
glans  penis,  especially  along  the  urethral  roof.  At  its  distal  end  this 
fossa  ends  in  the  external  meatus,  a  vertical  slit  on  the  antero-inferior 
aspect  of  the  glans.  The  meatus  is  the  narrowest  and  lead  dilatable 
portion  of  the   urethra   so    that  any   instrument   which  can   pass  the 


PLATE   XLVI  1 


FIG.  94. 


MUSCULAR   WALL 
OF    BLAOOE 


M  ASCULINUS 


UOINAL  MUS- 
OF   URETHRA 


Proximal   portions  of  urethra,  NA'itli  surrounding   parts. 
(Gerrish,  after  Testut. ) 


FIG.   9S. 


ST  POINT  OF 
URETHRAL  CURVE 


Outline  diagram  of  the  curved  portion  of  the  uieilira, 
showing    the    distances    from    and    the    relations    of    the 

different    pai'ts  to  ilie  symi^hysis.     (Testut.l 


THE  CURVES   OF  THE   URETHRA.  401 

meatus  should  pass  tlie  rest  ui'  -,1  normal  unthra.  To  allow  the  use  of 
large  sounds  or  instruments  in  the  trt-atmcnt  of  pathological  conditions 
of  the  rest  of  the  urethra  or  the  bladder  (/.  t.,  litholapaxy,  evstoscopv  of 
the  bladder,  etc.)  the  meatus  must  be  enlarf/ed  hi/  xlittiinj  it  inferiorly 
in  the  middle  of  the  frteuum.  The  meatus  may  be  foiKjt  nitnlhj  >iinnil, 
even  admitting  only  a  tine  i)robe.  This  conditi(»n  is  often  associated 
with  congenital  pliimosis,  and  from  it  urethral  spasm  may  result, 
though  perhaps  less  often  than  formerly  supposed  by  many.  Besides 
the  many  mucous  glands  found  in  all  parts  of  the  urethra,  es|)e- 
cially  in  and  near  the  navicular  fossa,  the  small  pits  or  htr.unff  of 
Morgagni  occur  in  the  spongy  ]K)rtion  in  longitudinal  rows,  a  median 
row  of  larger  lacunae  on  the  anterior  or  upper  wall  and  a  row  of  smaller 
lacuuse  on  either  side  of  it.  As  the  opening!^  of  these  lacunje  are  dindrd 
toward  the  meatus  the  larger  ones  may  catch  the  tip  of  a  small  sound 
or  bougie,  thereby  interfering  with  treatment  or  misleading  the  diag- 
nosis. Hence  instruments  should  be  passed  along  the  lower  wall  or 
floor  of  the  spongy  portion.  An  additional  reason  for  this  is  found  in 
the  presence  of  a  lacuna  of  large  size,  the  lacuna  maf/ua,  h  to  1  inch 
from  the  meatus  in  the  roof  of  the  navicular  fossa,  which  may  easily 
arrest  the  point  of  an  instrument.  It  is  nearly  covered  below  by 
a  semilunar  valve-like  fold  (the  valvule  of  Guerin). 

According  to  its  fixity  the  urethra  is  divided  into  a  fixed  and  a  mov- 
able part  (pars  fixa  and  pars  raobilis).  These  divisions  do  not  corre- 
spond to  the  preceding  but  more  to  the  next  following  division  for  the 
fixed  portion  includes  the  prostatic,  the  membranous  and  the  proximal 
two  inches  of  the  spongy  portion,  or  as  far  as  the  anterior  border  of  the 
suspensory  ligament.  The  membranous  portion  is  the  on/if  a/jxolutclt/ 
iurcd  part  and  therefore  of  the  greatest  importance  in  catheterization, 
for  we  must  direct  the  catheter  to  and  through  it;  its  position  does  not 
change  to  suit  the  catheter.  The  bulbous  jjortion  is  the  wjcw/  movable 
2)art  of  the  fixed  pjortion  and  this  part  lies  immediately  in  front  of  the 
most  fixed  portion.  This  is  one  reason  for  the  difficulty  of  directing 
the  point  of  the  catheter  or  sound  into  the  membranous  portion,  fL>r  the 
bulb  may  be  easily  pushed  backward  or  sideways.  The  rc.-<t  of  the 
spongy  portion  of  the  urethra  is  the  pars  mobilis,  and  it  depends  for  its 
position  and  direction  upon  that  of  the  ])enis.  For  the  introduction  of 
instruments  this  portion  may  be  put  in  the  most  suitable  position  for 
the  purpose. 

In  direction  the  urethra  is  median  but  may  deviate  somewhat 
laterally  in  micturition.  It  presents  a  curve,  concave  forward  and 
upward,  beneath  the  symphysis,  the  subpubic  curve,  and  a  prepubic 
curve  where  the  fixed  and  movable  portious  join.  The  latter  curve, 
with  its  concavity  downward,  is  at  the  junction  of  the  fixed  and  mov- 
able jiortions  and  is  present  in  the  flaccitl  state  of  the  jKMiis  but  is 
obliterated  when  the  penis  is  erected  or  raised  up.  Hence  in  the  pas- 
sage of  instruments  we  raise  the  penis  and  have  to  deal  only  with  the 
su7>pubic  curve.  The  latter  curve  is  mo.^t  marked  in  the  membrainuis 
and  bulbous  portions,  though  it  is  continued  slightly  in  the  uj>ward 
26 


402  PELVIS  AND  PERINEUM. 

direction  in  the  prostatic  urethra,  which  is  nearly  vertical,  and  in  the 
forward  direction  about  to  the  prepubic  curve  or  the  end  of  the  fixed 
portion,  though  the  anterior  portion  of  this  rises  but  little  {^  to  \  inch) 
above  the  level  of  the  lowest  point  of  the  curve.  The  curve  (Fig.  90) 
is  described  as  being  an  arc  of  a  circle  having  a  diameter  ranging,  ac- 
cording to  different  authors,  from  3|  to  4|  inches,  the  chord  of  the  arc 
measuring  about  2^  to  2|  inches.  The  curve  is  sharper  in  small,  thin 
men  and  flatter  in  large  stout  men.  The  subpubic  curve  belongs  to 
the  fixed  portion  of  the  urethra  and  hence  metal  urethral  instruments 
are  made  with  a  definite  curve  to  allow  them  to  take  the  curve  of  the 
urethra  without  letting  the  tip  impinge  or  catch  on  the  floor.  It  is 
possible  to  pass  a  stiff  straight,  or  nearly  straight,  instrument  into  the 
bladder  but  not  without  painful  tension  of  the  connections  of  the 
urethra,  especially  the  suspensory  ligament,  and  hence  it  is  often  done 
under  anaesthesia  and  only  for  certain  objects,  as  litholapaxy,  etc. 

The  dividon  into  anterior  and  posterior  urethrae  occurs  between  the 
membranous  and  the  bulbous  portions  at  the  level  of  the  superficial  layer 
of  the  triangular  ligament.  This  division  is  of  practical  importance 
from  a  pathological,  prognostic  and  therapeutic  standpoint.  The  dis- 
charge from  a  urcthritii<  of  the  anterior  urethra  drips  from  the  meatus 
and  injections  into  this  part  escape  at  the  same  point.  A  urethritis  also 
is  often  limited  to  this  part  for  the  compressor  urethras  muscle  offers 
an  obstacle  to  its  further  extension.  The  complications  of  such  an 
anterior  urethritis  are  principally  chordee,  gleet  and  stricture.  When 
an  iii^ammation  extends  into  the  posterior  urethra  or  an  injecting 
catheter  is  introduced  beyond  the  compressor  urethrse  muscle  the  dis- 
charge or  injection  flows  into  the  bladder  and  does  not  appear  at  the 
meatus.  The  inflammation  here  is  also  liable  to  spread  to  the  bladder, 
vas  deferens,  epididymis,  seminal  vesicles,  prostate  and  kidneys  by 
continuous  extension  or  otherwise,  hence  the  prognosis  of  posterior 
urethritis  is  more  grave.  By  using  considerable  pressure  and  prevent- 
ing the  escape  at  the  meatus  fluid  may  be  injected  into  the  bladder 
from  any  jioint  in  the  anterior  urethra. 

Embryologically  also  the  posterior  urethra  is  of  a  different  formation 
{i.  e.,  from  the  urogenital  sinus)  and  corresponds  to  the  urethra  and 
vestibule  in  the  female,  while  the  anterior  urethra  is  formed  by  the 
genital  folds  of  the  external  genitals. 

The  length  of  the  urethra  from  the  internal  to  the  external  meatus 
varies,  but  averages  about  seven  inches.  It  varies  with  the  length  of 
the  penis ;  when  the  latter  is  contracted  to  the  utmost  it  may  be  con- 
siderably (over  an  inch)  shorter,  when  the  penis  is  more  or  less  erected 
or  is  pulled  upon  during  catheterization  the  urethra  may  measure  eight 
inches  or  more.  Hypertrophy  of  the  prostate  also  lengthens  the  urethra, 
a  fact  which  is  useful  in  the  diagnosis  of  this  condition.  The  length 
of  the  urethra  at  birth  is  5-6  cm.,  in  children  of  five  years  8-10  cm., 
at  the  beginning  of  puberty  10-12  cm. 

The  normal  caliber  or  diameter  of  the  urethra,  being  that  of  a  cylin- 
der which   separates  the  walls  without   stretching  them,  can  only  be 


RELATIVE  POSITION  OF  TIIK   URETHRA.  403 

given  approximately  except  for  the  external  meatus.  Sappey  states 
that,  exclusive  of  the  meatus,  the  urethral  circumference  ranges  between 
15  and  18  mm.,  so  that  a  No.  15  (French)  sound  could  l>e  passed 
without  stretching  the  canal.  Tlio  innitns  is  about  ]  of  an  inch  in  its 
long  diaiiietei'.  Of  more  practical  importance  is  the  absolute  or  rela- 
tive distensibility,  which  ((rcr(i(/(:s  10.5  mm.  in  its  diameter  (Jocssel, 
Waldeyer).  The  distensibility  varies  in  different  parts  and  as  we  pass 
from  end  to  end  of  the  urethra  we  find  that  a  narrow  jjorlion  alternates 
with  a  wider  portion.  Thus  the  narrow  portions  are,  in  order,  the 
external  meatus,  spongy  portion,  mcml)ranous  portion  and  internal 
meatus;  the  wider  portions  are  the  fossa  navicularis,  the  bulbous  por- 
tion and  the  prostatic  portion.  In  order  of  distensibility  we  find  the 
meatus  the  least  (listcnsil)le,  next  the  membranous  portion,  the  spongy 
portion,  the  prostatic  portion  and  lastly  the  l)ull)()us  portion,  which  is 
the  most  distensible.  The  different  parts  should  distend  so  as  to  admit 
the  following  sounds  of  the  French  scale :  the  meatus  No.  24,  the 
spongy  portion  Nos.  28-30,  the  bulbous  portion  No.  32,  the  mem- 
branous portion  Nos.  26-27,  and  the  prostatic  portion  Nos.  30-32. 

Otis  proved  that  the  distensibility  of  the  urethra  was  greater  than 
formerly  supposed,  though  Guyon  showed  that  by  the  passage  of  large 
sounds,  31-34  (French),  on  the  cadaver  lacerations  were  produced, 
especially  on  the  floor  of  the  penile  portion.  According  to  Otis  there 
exists  a  constant  ratio  of  nine  to  four  beticeen  the  circumference  of  the 
penis  and  that  of  the  distended  urethra.  Apart  from  the  fact  that  it 
is  improbable  that  such  an  exact  mathematical  ratio  is  constant,  it  is 
difficult  in  measuring  an  organ,  so  variable  in  size  as  the  penis,  to 
measure  the  latter  in  the  same  condition  of  relative  size  in  different 
cases.     Still  Otis'  law  is  of  value  as  a  practical  guide  to  the  surgeon. 

The  relative  position  of  some  parts  of  the  urethra  may  be  more 
fully  given.  The  internal  meatus  is  on  a  level  with  the  middle  of  the 
symphysis,  or  somewhat  below  or  above  it.  It  lies  above  this  ])oint 
in  young  subjects,  and  not  infre(|Uently  in  adults.  The  prostatic  portion, 
in  whole  or  in  great  part,  lies  above  the  horizontal  plane  passing 
through  the  bottom  of  the  symphysis,  so  that  this  portion  is  often 
entirely  behind  the  symphysis.  The  deepest  point  of  the  subpubic 
curve  is  in  the  bulb  and  lies  18  to  20  mm.  from  the  subpubic  angle, 
usually  more  or  less  behind  the  vertical  plane  of  this  angle,  but  some- 
times beneath  or  even  in  front  of  it.  We  have  already  referred  to  the 
effect  on  the  frequency  of  stricture  here  of  its  being  the  most  depend- 
ent point  of  the  curve  in  the  erect  posture.  The  prepubic  curve  lies 
below  the  horizontal  plane  of  the  subpubic  angle,  and  usually  1  to  ]■ 
of  an  inch  above  the  lowest  level  of  the  urethra  in  the  bulb,  so  that 
from  the  latter  the  urethra  extends  slightly  upward  as  well  as  forward, 
though  it  may  be  horizontal.  Betwee)i  the  suh}>u/)lc  rurrr  nf  flu  unthra 
and  the  si/nijihi/sis  lie  the  dorsal  vein  of  the  penis,  the  pudendal  jilexus 
and  the  continuation  t)f  the  perivesical  fat. 

On  cross  section  the  enijity  urethra  is  represented  by  a  fissure  which 
is  vertical  at  the  external   meatus,  tmnsverse  in  the  spongy  portion, 


404  PELVIS  AXD  PERINEUM. 

stellate  in  the  membranous  portion  and  like  an  inverted  U  in  the 
prostatic  portion.  A  form  of  rifling  is  involved  by  this  progressive 
change  in  shape  Avhich  may  account  for  the  spiral  form  of  the  normal 
stream  of  urine.  In  addition  the  mucous  membrane  of  the  collapsed 
urethra  is  in  longitudinal  folds. 

Sphincters  of  the  Urethra. — The  fixed  portion  of  the  urethra 
passes  through  a  continuous  layer  of  encircling  muscle  fibers,  both 
plain  and  striated.  This  is  formed  of  several  parts,  of  which  the  most 
distal  is  the  bulbocavernosus  muscle.  The  internal  sphincter  is  com- 
posed of  plain  muscle  fibers,  derived  from  the  deep  layers  of  the  tri- 
gonum,  which  pass  downward  and  forward  obliquely  encircling  the 
upper  part  of  the  prostatic  urethra  and  meeting  in  front  of  it.  This 
does  not  include  but  is  be/oiv  the  circular  fibers  of  the  bladder  which 
are  aggregated  around  the  internal  meatus  and  form  a  ring,  the  "an- 
niiht.s  )ir<ilirn/ls^''  which  is  completed  posteriorly  by  the  trigonal  muscle. 
The  external  or  voluntary  sphincter  is  composed  chiefly  of  the  fibers  of 
the  compressor  urethrse  muscle,  though  striped  fibers  continuous  with 
them  surround  the  lower  half  of  the  prostatic  urethra,  especially  in 
front.  Distally  the  compressor  urethrse  adjoins  the  bulbocavernosus 
muscle. 

The  urethral  walls  also  contain  unstriped  longitudinal  fibers,  con- 
tinuous with  those  of  the  bladder,  and  some  circular  fibers,  as  far  as 
the  lower  end  of  the  bulbous  portion.  There  is  but  little  muscular 
tissue  in  the  walls  of  the  movable  portion  (pars  raobilis).  The  muscular 
tissue  of  the  urethra  appears  to  have  a  peridultic  action,  whereby  a 
catheter  left  in  the  urethra  or  the  last  drops  of  urine  are  gradually 
expelled.  Cases  of  reverse  peristalsis  are  also  known  where  a  flexible 
instrument  insecurely  tied  has  been  pressed  into  the  bladder.  As  already 
noted  the  external  sphincter  is  the  dividing  line  between  the  anterior 
and  the  posterior  urethra  and  is  also  the  cause  of  spasmodic  stricture.  The 
latter  is  usually  due  to  a  reflex  from  some  point  of  irritation  in  the 
urethra  (stricture,  granular  patch,  etc.),  and  is  often  caused  by  the 
rough  use  of  instruments ;  occasionally  it  may  be  due  to  an  abnormally 
small  meatus.  It  commonly  yields  to  steady  easy  pressure.  The 
retention  of  urine  following  operations  on  the  rectum,  anus,  etc.,  is 
thought  by  many  to  be  the  result  of  vesical  inhibition  rather  than 
urethral  spasm. 

Changes  According  to  Age. — In  children  the  urethra  is  shorter  (see 
page  402)  and  narrower,  but  Keegan  has  shown  that  the  urethra  of  a 
male  infant  one  year  old  will  admit  instruments  for  litholapaxy,  and 
that  at  two  to  three  years  of  age  a  No.  9  and  at  eight  to  ten  years  a 
No.  11  lithotrite  may  be  passed.  Hence  lithotrity  and  litholapaxy 
may  be  performed  upon  quite  young  infants.  The  subpubic  curve  in 
infants  is  also  sharper,  owing  to  the  high  position  of  the  bladder.  In 
old  age  there  occurs  a  dilatation  of  the  fossa  of  the  bulb  and,  in  cases 
of  enlarged  prostate,  a  lengthening  and  narrowing  of  the  prostatic  por- 
tion, often  with  an  increased  forward  curve  of  the  vesical  end  which  tends 
to  make  the  tip  of  instruments  catch  on  the  floor,  in  the  prostatic  sinus 


THE  PENIS.  405 

Catheterization,  or  the  introduction  of  instruments,  is  of  such  im- 
portance that  we  may  repeat  what  has  been  said  in  different  places 
above.  Use  the  largest  instrument  that  will  readily  pass  as  it  is  ealer 
and  easier  and  sometimes  passes  where  smaller  sizes  will  not.  In  the 
spovffij  urrfhni  pass  the  instrument,  especially  if  it  he  small,  along  the 
floor  to  avoid  catching  the  tip  in  the  lacuna  magna,  or  in  the  dorsal 
row  of  large  lacunje  behind  it.  The  movable  urethra  (pars  mobilis) 
accommodates  itself  to  the  shape  and  direction  of  the  instrument,  which 
is  commonly  held  over  and  parallel  to  ]^)upart^s  ligament,  the  penis 
being  held  upwards  and  to  cither  side  to  ol)literate  the  prepubic  curve. 
When  the  bulb  is  reached  the  handle  of  the  instrument,  now  held  in 
the  median  line,  is  depressed  to  elevate  the  tip  to  the  roof  so  as  to  find 
the  opening  into  the  memhranous  portioii.  The  finger  in  the  rectum  or 
perineum  may  also  help  to  raise  the  tip  of  the  instrument.  If  xpn^m 
exists  use  only  slight  steady  pressure,  principally  the  weight  of  the 
instrument;  never  press  hard.  Most /f//.sc  y^r/.s.sayf.s- start  from  the  de- 
pressed floor  of  the  fossa  bulbi,  posteriorly.  The  tip  of  the  instrument 
should  continue  to  follow  the  roof  of  the  membranous  and  jji-osfafic 
urethra'  so  as  to  follow  the  curve  of  the  urethra  and  to  avoid  the  utricle 
and  prostatic  sinuses  ;  this  is  done  by  a  gentle  depression  of  the  handle. 

The  urethra  may  be  ruptured  by  being  crushed  between  the  pubic 
arch  and  a  hard  substance,  astride  of  which  the  patient  falls.  The 
parts  of  the  urethra  most  often  injured  are  the  membranous  and  l)ulb- 
ous  portions,  the  latter  especially  when  the  body  is  bent  forward,  when 
a  considerable  length  of  the  spongy  urethra  may  be  crushed. 

The  commonest  pathological  conditions  that  affect  the  urethra  are 
urethritis,  usually  gonorrhceal,  and  its  sequelje,  gleet  and  organic 
stricture.  The  latter,  as  stated  above,  is  most  common  in  the  bul- 
bous and  membranous  portions,  as  is  also  stricture  following  rup- 
ture of  the  urethra.  The  obstinacy  of  a  urethritis  in  yielding  to  treat- 
ment is  in  part  due  to  the  length  and  narrowness  of  the  canal,  to  the 
dilated  portions  which  serve  as  reservoirs  for  secretion  and  to  the 
numerous  folds,  lacunae  and  glands. 

The  Penis. 

The  skin  covering  the  body  of  the  organ  is  continuous  with  that  of 
the  scrotum  and  is  destitute  of  fat,  highly  elastic,  thin  and  very  mov- 
able. Owing  to  the  latter  fact,  due  to  the  looseness  of  the  subcutane- 
ous tissue,  the  skin  should  not  be  drawn  too  strongly  downwards  over 
the  glans  in  circumcision  or  amj)utation  of  the  penis,  otherwise  the 
operator  may  be  startled  by  seeing  the  skin  above  the  section  retract  to 
the  base  of  the  organ.  In  very  large  scrotal  hernia^  or  hydroceles  the 
skin  and  loose  outer  coverings  of  the  j)enis  may  be  drawn  upon  to  such 
an  extent  to  cover  the  scrotal  mass  that  the  penis  represents  a  mere 
depression  in  this  mass  from  which  the  urine  escaj)c8. 

From  the  cervix  the  skin  extends  down  over  the  glans  a  varial'lo 
distance  and  is  then  (K)ubled  upon  itself  to  form  the  prepuce  or  foreskin. 
The  inner  layer  of  the  prepuce  is  attached  more  or  less  firndy  around 


406  PELVIS  AND  PERINEUM. 

the  cervix  to  be  thence  continued  over  the  glans,  at  the  end  of  which, 
dipping  into  the  meatus  for  a  quarter  of  an  inch,  it  is  continuous  with 
the  urethra]  mucosa.  The  prepuce  at  birth  is  relatively  very  long, 
more  than  covering  the  glans. 

When  the  prepuce  is  so  tight  as  to  prevent  its  easy  retraction  the 
condition  is  called  phimosis.  The  preputial  orifice  may  only  admit  a 
small  probe  or,  rarely,  may  be  completely  closed.  Phimosis  may 
cause  diJficnU  micturition,  if  the  opening  at  the  end  of  the  prepuce  is 
very  small,  and  in  any  case  balanitis,  which  is  due  to  retained  secretions 
and  is  followed  by  adhesions  of  the  prepuce  to  the  glans.  Incomplete  de- 
velopment of  the  glans,  incontinence  of  urine,  especially  nocturnal,  and 
greater  liability  to  contract  venereal  diseases  may  also  result  from 
phimosis.  A  long  series  of  reflex  nervous  conditions  has  been  attrib- 
uted to  the  same  cause,  often  without  sufficient  reason.  Besides  the  con- 
genital form,  phimosis  may  also  be  acquired  as  the  result  of  inflammatory 
swelling,  due  to  the  presence  of  ulcers  or  balanitis  beneath  the  prepuce. 

Owing  to  the  serious  conditions  resulting  from  phimosis  it  requires 
appropriate  treatment.  In  many  cases  of  congenital  phimosis  stretching 
the  prepuce  may  be  all  that  is  necessary,  in  others  a  little  dorsal  slit 
is  sufficient,  while  still  others  with  a  long  narrow  foreskin  require  cir- 
cumcision. The  main  object  of  this  is  to  uncover  the  glans.  It  is 
unnecessary,  if  it  is  possible,  to  divide  the  two  preputial  layers  at  the 
same  level,  at  the  base  of  the  glans.  No  special  instruments  are  re- 
quired. We  divide  the  outer  layer  at  the  proper  level,  then  slit  up 
the  inner  layer,  which  covers  the  glans  on  its  dorsum.  Then  we  can 
loosen  the  adhesions  with  the  glans  which,  when  present,  prevent  the 
two  layers  being  cut  at  the  same  level.  We  leave  a  cuff  of  the  inner 
layer  of  varying  size  and  suture  the  two  layers.  It  is  interesting  to 
note  that  shortly  before  birth  the  inner  layer  of  the  foreskin  and  the 
glans  are  adherent  throughout. 

When  a  foreskin,  narrow  from  birth  or  as  the  result  of  inflamma- 
tion, is  forcibly  retracted  over  the  glans  it  may  remain  caught  in  the 
cervix  owing  to  the  difficulty  of  pulling  it  down  over  the  corona. 
The  pressure,  especially  that  of  the  narrowest  part,  the  preputial 
margin,  causes  the  glans  to  swell,  which  decreases  the  chance  of  reduc- 
tion and  increases  the  pressure  so  that  sloughing  occurs  at  the  line  of 
pressure.  This  condition,  called  paraphimosis,  demands  relief  to  save 
the  glans,  etc.,  from  sloughing.  We  may  sometimes  replace  the  fore- 
skin after  reducing  the  size  of  the  glans  by  pressure,  but  other  cases 
require  a  longitudinal  incision  on  the  dorsum,  over  the  constricting 
band  and  down  to  the  sheath  of  the  corpus  cavernosum.  In  the  median 
line  inferiorly  there  is  the  indication  of  a  median  raphe,  continuous 
with  that  of  the  scrotum,  along  which  the  coverings  of  the  penis  are 
more  or  less  adherent  together. 

The  skin  is  lined  by  a  thin  dartos,  a  muscular  layer  with  longitudinal 
fibers  continuous  with  the  dartos  of  the  scrotum.  At  the  end  of  the 
prepuce  the  muscular  fibers  are  arranged  circularly,  forming  a  kind  of 
sphincter.     The  dartos  lines  both  layers  of  the  prepuce  between  which 


ERECTION  OF  THE  PENIS.  407 

is  an  extension  of  the  loose  subcutaneous  tissue,  which  connects  the 
skin  1  >osely  with  the  fascia  penis  and  renders  the  ftjrnier  so  movtibh:. 
This  hjose  tissue  accounts  for  the  stuldcn  roid  grcnl  .sirdlin(f  that  may 
occur  in  the  prepuce  or  on  the  penis  as  the  result  of  inflammation, 
oedema,  or  the  extravasation  of  blood,  urine,  etc.  The  sujjrrjifln/  wmela 
and  nerveH  are  contained  in  this  tissue.  The  skin  covering  the  cervix 
and  the  proximal  side  of  the  corona  is  lined  by  this  loose  tissue,  but  there 
is  no  subcutaneous  tissue  over  the  glans.  This  accounts  for  the  fact 
that  a  chancre  on  the  glans  shows  but  little  if  any  induration  (parch- 
ment induration)  while  a  chancre  on  the  cervix  or  the  proximal  side  of 
the  corona,  a  favorite  position,  has  a  ty[)ical  induration  i)^  the  base,  due 
to  tiie  infiltration  of  tiie  suljcutaneous  connective  tissue. 

The  fascia  penis  is  the  highly  elastic  fibrous  sheath  investing  the 
three  erectile  bodies  which  form  the  bulk  of  the  penis.  It  extends  as 
far  as  the  cervix,  around  which  it  is  firmly  attached  to  the  erectile 
bodies  and  fuses  with  the  skin.  At  the  base  of  the  pendulous  portion 
of  the  penis  this  fascia  is  continuous  with  the  superficial  perineal  fascia 
behind  and  the  suspensory  ligament  in  front.  It  covers  the  deep 
dorsal  vessels  and  the  lateral  tributaries  of  the  dorsal  vein,  ijy  com- 
pressing which  it  contributes  to  the  erection  of  the  penis,  after  this 
condition  has  once  become  established.  In  this  it  is  aided  by  those  fibers 
of  the  bulbocavernosi  and  the  ischiocavernosi  which  encircle  the 
dorsum  of  the  corpora  cavernosa  and  thus  compress  the  dorsal  vein. 
The  contraction  of  the  compressor  urethne  muscle  and  the  pressure  of 
the  ])enis  against  the  pubic  arch  by  means  of  the  ischiocavernosi 
muscles  also  compress  this  vein  and  thus  assist  in  erection  of  the  penis. 
Apart  from  these  causes  of  erection,  which  act  by  hindering  the  venous 
return,  the  vaso-dilator  nerves  act  by  increasing  the  arterial  su])plv  of 
the  erectile  bodies  through  the  dorsal  arteries,  the  arteries  of  tiu-  ijulb 
and  of  the  corpora  cavernosa.  The  .spinal  center  of  erection  is  in  the 
lumbar  enlargement  and  may  i)e  stimulated  by  any  local  irritation  ; 
it  also  receives  exciting  and  inhii)itory  stimuli  from  the  brain. 
When  the  cerebral  inhibitory  action  is  shut  off,  by  an  injury  or  dis- 
ease of  the  spinal  cord  above  this  center,  there  is  liable  to  be  a  condi- 
tion of  chronic  partial  erection,  known  as  priapi.sm. 

Besides  the  active  erection,  in  which  arterial  supply  and  venous 
return  are  both  concerned,  there  may  be  a  jtassirr  erertion,  such  as  that 
due  to  the  jiressure  of  a  full  bladder  on  the  venous  plexus  (prostatit-o- 
vesical)  through  which  the  dorsal  vein  of  the  peuis  empties  into  the 
branches  of  the  internal  iliac  vein.  The  pro])osal  to  tic  the  dorsal 
vein  to  assist  an  incomplete  erection  of  the  penis  has  been  tried  with 
some  success.  A  constricting  band  around  the  penis  causes  rapid  and 
extensive  swelling  of  the  organ,  hence  in  tying  in  a  catheter  it  is  best 
not  to  employ  tajjcs  around  the  penis  and  no  bandage  aroiuid  the  jx-nis 
should  be  tight.  The  large  deep  dorsal  rein  (Fig.  9(5)  of  the  penis  is 
usually  single  and  occupies  the  groove  between  the  two  corpora  caver- 
nosa superiorly.  It  pierces  the  triangular  ligament  one  half  inch  be- 
low the  pubic  arch.     The  thick  elastic  sheath  of  tlu'  cor|x>ra  cavernosa, 


408  PELVIS  AND  PERINEUM. 

called  tunica  alhuginea  from  its  whitish  appearance,  consists  of  an 
outer  layer  of  longitudinal  fibers  covering  both  corpora  and  an  inner 
layer  of  circular  fibers  forming  a  separate  sheath  for  each.  The  latter 
forms  a  septum  between  the  two  which  is  incomplete  anteriorly  so  that 
any  inequality  in  the  blood  supply  of  the  two  corpora  may  be  equalized. 

The  suspensory  ligament  of  the  penis  connects  the  corpora  cavernosa 
with  the  front  of  the  symphysis  pubis.  In  front  of  this  ligament  we 
have  the  movable  portion  or  "  body  "  of  the  penis,  which  serves  as  the 
pars  copulatrix  and  corresponds  to  the  pars  mobilis  of  the  urethra. 
The  angle  of  the  penis,  immediately  in  front  of  the  suspensory  liga- 
ment, is  only  present  in  the  flaccid  condition  of  the  organ.  In  erec- 
tion the  "  body  "  of  the  penis  comes  into  line  with  the  "  root,^^  which 
corresponds  to  the  two  crura  of  the  corpora  cavernosa  which,  diverg- 
ing behind  the  suspensory  ligament,  are  attached  to  the  ischiopubic 
rami. 

Each  corpus  cavernosum  measures  about  6  x  ^  inch,  which  increases 
by  a  third  or  more  in  erection.  The  corpus  spongiosum  begins  behind  in 
an  enlargement,  the  bulb,  surrounding  the  floor  and  sides  and,  further 
forwards,  the  entire  urethra.  It  ends  in  front  in  a  heart-shaped 
enlargement,  the  glans  penis,  which  overlaps  the  rounded  anterior 
extremities  of  the  corpora  cavernosa.  The  bulb,  measuring  H  inches 
long  and  |  inch  broad,  abuts  against  the  central  point  of  the  perineum, 
1|  cm.  in  front  of  the  anus.  It  presents  inferiorly  an  incomplete 
median  septum,  indicated  on  the  surface  by  a  slight  furrow,  hence  if 
the  bulb  is  incised  in  the  exact  median  line  the  bleeding  is  less  than  it 
otherwise  would  be.  The  bulb  is  invested  by  a  fibromuscular  sheath, 
continuous  with  the  superficial  layer  of  the  triangular  ligament,  and 
by  the  hn/bocavcrnosus  muscle,  whose  action  assists  in  ejaculation,  in 
expelling  the  last  drops  of  urine  and  in  the  erection  of  the  penis.  The 
glans  is  twice  as  long  on  its  upper  as  on  its  under  surface  and  its  pro- 
jecting base  or  corona,  which  limits  the  cervix,  is  interrupted  in  the 
median  line  inferiorly  by  a  small  median  fold,  the  frenum  prseputii, 
continuous  with  the  inner  layer  of  the  prepuce.  The  frenum  grooves 
the  under  surface  of  the  glans  as  far  as  the  inferior  angle  of  the 
meatus,  and  contains  vessels  of  some  size  which,  if  ruptured  in  coitus, 
in  case  the  frenum  is  unusually  short,  or  eroded  by  chancroidal  ulcer- 
ation, may  cause  considerable  loss  of  blood.  In  erection  both  the  glans 
and  the  rest  of  the  corpus  spongiosum  are  soft  as  compared  with  the 
corpora  cavernosa  and  thus  they  offer  no  resistance  to  the  passage  of 
semen  or  urine. 

When  a  urethritis  extends  beyond  the  mucosa  and  causes  an  indura- 
tion of  the  submucous  structures  the  corpus  spongiosum  loses  its 
elasticity,  so  that  in  erection  it  cannot  elongate  but  acts  like  the  string 
of  a  l)o\v  and  bends  down  the  corpora  cavernosa,  so  that  the  erected 
penis  is  curved  backward.  This  condition,  known  as  chordee,  is  very 
painful,  owing  to  the  traction  on  the  inflamed  urethra  and  corpus 
spongiosum.  The  erected  corpora  cavernosa  may  be  '\fractured  "  by 
forcible  flexion  in  coitus  and  otherwise.     Such  an  injury  is  irreparable; 


THE  SCEOTU.V.  409 

it  causes  an  extravasation  of  blootl,  interrupts  the  continuity  of  the 
erectile  tissue  and  prevents  the  .striiight  erection  of  the  penis,  for  the 
corpus  cavernosum  so  affected  can  not  lengthen  as  much  as  the  other, 
or  if  l)otii  are  affected  a  portion  of  both  can  not  become  erected. 

The  lymphatics  of  the  penis,  including  those  of  the  urethral  nni- 
cosa,  enter  the  inner  or  middle  group  of  the  superficial  inguinal  lymph 
nodes.  Some  of  the  deeper  lymj)hatics  of  the  erectile  bodies  may 
perhaps  enter  the  pelvic  lymph  nodes. 

Congenital  Malformations. — Hypospadias,  the  commonest  form,  is 
due  to  a  partial  or  complete  failure  to  unite  on  the  |)art  of  the  g'liital 
folds,  on  the  under  aspect  of  the  penis.  These  folds  l)y  their  union 
convert  the  groove  between  them  into  the  spongy  portion  of  the 
urethra.  This  failure  to  unite  may  affect  the  entire  length  of  the 
spongy  urethra,  so  that  the  urethral  opening  is  in  the  perineum ;  or  it 
may  occur  at  the  end  and  involve  only  the  glans,  so  that  the  opening 
is  just  back  of  the  glans;  or  it  may  occur  at  any  intermediate  point. 
In  comp/efe  Jiypospadias  the  corpus  spongiosum  is  wanting  or  defective, 
being  replaced  largely  by  fibrous  tissue  which  does  not  lengthen  in 
erection  of  the  penis,  so  that  in  this  condition  the  penis  is  bent  sharply 
downward  and  backward.  Complete  hypospadias  is  one  of  the  ele- 
ments which  go  to  make  u\)  jjseu(l()-h<'rm<ijjhro(Utis)n. 

Epispadias  is  due  to  a  failure  of  more  or  less  of  the  urethra  to  close 
on  its  upper  aspect.  The  opening  is  usually  found  in  front  of  tiie 
symphysis  and  the  condition  is  often  associated  with  a  separation  of 
the  symphysis  and  extroversion  of  tlie  bladder ;  hence  it  is  due  to 
malformation  at  an  early  period  of  development.  It  is  more  difficult 
to  explain  embryologically. 

Besides  being  the  most  frequent  situation  for  chancroid,  condylo- 
mata and  the  initial  lesion  of  syphilis  the  distal  portion  of  the  penis 
may  be  affected  by  cancer.  This  commonly  takes  the  form  of  epithe- 
lioma of  the  glans  or  prepuce  and  most  cases  are  said  to  occur  when 
phimosis  exists  or  has  existed.  The  inguinal  nodes  may  be  involved 
early  and  should  always  be  removed. 

The  Scrotum. 

Although  in  descriptive  anatomy  this  term  is  often  api)lied  to  the 
skin  and  dartos  only,  yet  topographically  we  must  consider  with  it  the 
other  envelopes  of  the  testic-le  and  of  the  lower  part  of  the  spermatic 
cord.  The  lax  scrotum  is  admirably  suited  to  profert  f/ie  (e.-<(i,-/,s  i)y 
allowing  them  to  move  about  so  readily  and  thus  to  escape  injury.  It 
will  be  noticed  that  the  layers  of  the  scrotum  correspond  to  those 
covering  the  sac  of  an  oblique  inguinal  hernia.  The  /eft  /xdj  oi'  the 
scrotinn  is  commonly  larger  than  the  right.  In  the  infant  the  scrotum 
is  larger  al>ove  than  below,  vice  versa  in  the  adult. 

The  skin  is  thin  and  transparent,  showing  an  ecchymosis  beneath  it 
quickly  and  distinctly.  It  is  very  e/asfic  .so  that  it  allows  of  great  dis- 
tension, as  in  large  hernia%  hydroceles  and  tiunors.  It  is  al.<o  redun- 
dant,  so  that   the  loss  of  a  portion    by  excision  or  sloiighing  will   not 


410  PELVIS  AXD   PERINEUM. 

be  missed.  Excision  of  redundant  scrotum  has  been  employed  in  the 
treatment  of  varicocele.  The  skin  forms  a  single  pouch,  but  a  median 
raphe,  continuous  with  that  on  the  under  surface  of  the  penis  and  in 
the  perineum,  indicates  its  embryological  formation  from  two  lateral 
halves.  The  more  or  less  transverse  rugce,  into  which  the  skin  is 
thrown  by  the  contraction  of  the  underlying  dartos,  favor  the  accumu- 
lation of  dirt  and  moisture,  the  irritation  due  to  which  may  account 
for  the  epitheliomata  and  eczema,  not  uncommon  here. 

The  dartos  is  very  yascular  and  closely  lines  the  skin,  especially  in 
the  lower  part  of  the  scrotum.  Its  dark  reddish  color  depends  upon 
the  unstriped  muscle  fibers  that  it  contains,  the  contraction  of  which 
causes  the  rug(e  of  the  skin.  These  rugae  are  a  sign  of  health  ;  they 
disappear  in  enfeebled  conditions  or  under  the  relaxing  effects  of  heat, 
and  the  scrotum  becomes  smooth  and  pendulous.  In  wounds  of  the 
scrotum,  especially  with  loss  of  substance,  the  contraction  of  the  dartos 
is  of  value  in  closing  the  gap.  Such  a  contraction  may  be  stimulated 
by  cold  applications  or  mental  emotions,  but  not  by  electricity.  Con- 
versely warm  applications  relax  the  dartos  and  thus  may  prevent  the 
inversion  of  the  edge  of  an  incised  wound  of  the  scrotum,  which  inter- 
feres with  its  proper  suture.  Its  contraction  is  slow  and  peristaltic  and 
shortens  the  scrotal  pouch.  The  dartos  forms  a  separate  pouch  for  each 
testis  and  the  median  meeting  of  these  two  sacs  forms  the  septum  scroti, 
which  extends  from  the  raphe  to  the  root  of  the  penis.  The  muscle 
fibers  of  the  dartos  run  for  the  most  part  longitudinally  so  that  the 
rugae  are  transverse.  It  is  continuous  with  the  superficial  fascia  of  the 
groin  and  perineum  and  with  the  dartos  of  the  penis,  and  like  the 
latter  contains  no  fat. 

The  skin  and  dartos  form  ])ractically  a  single  layer  connected  by  a 
loose  connective  tissue  layer  with  a  composite  layer  formed  by  the  other 
envelopes  of  the  testicle,  etc.  For  practical  and  surgical  purposes  the 
testis,  etc.,  is  covered  by  only  two  composite  layers,  loosely  united  by 
this  loose  connective  tissue  layer.  This  loose  fatless  connective  tissue 
layer  allows  large  extravasations  of  blood  to  occur  after  injuries.  Owing 
to  the  dependent  position  of  the  scrotum  this  tissue  may  early  become 
very  oedematous  in  a  case  of  dropsy.  It  allows  the  testis  and  cord  and 
their  envelopes  to  be  enucleated  through  an  incision  or  protruded 
through  a  wound  of  the  scrotum  proper.  By  many  this  layer  is  re- 
garded as  coidinuous  v-ith  the  intercolumnar  fascia  at  the  external  ring 
and  hence  as  being  the  crternaf  spermatic  fascia,  while  others  describe 
the  latter  as  more  membranous  and  as  forming  a  fascial  covering  of 
the  cremaster  muscle.  It  is  continuous  with  a  similar  layer  in  the 
penis,  and  thus  extravasations  of  any  sort  may  readily  extend  from  the 
scrotum  to  the  penis  and  vice  versa.  It  is  also  continuous  witli  the 
dee))  layer  of  the  superficial  perineal  fascia. 

The  cremasteric  and  infundibuliform  layers,  continuous  in  the  inguinal 
canal  with  the  internal  oblique  muscle  and  the  infundibuliform  fascia 
respectively,  are  lined  by  the  parietal  layer  of  the  tunica  vaginalis  and 
form  a  composite  envelope  for  the  testis.     This  envelope  is  connected 


r    2)     0 


» 

~ 

— 

o 

(fl 

0) 

T) 

H 

J 

a 

C    _, 
2' 

— ' 

"  • 

r> 

0 

^ 

(/) 

3C 

so 

-' 

'X 

Z 

< 

0) 

.J 

*— 

ti 

CD 

0/ 

T 

<— 

^ 

(0 

CQ 

IT 

CD 

^.... 

r» 

^ 

X 

ft) 

7) 

2 

> 
■n 

< 

o 

-^ 

~ 

|Z' 

-n 

0 

< 

0 

'< 

(b 

mJ 

r. 

X 

— 

^ 

O 

r*" 

^ 

-1 
c 

r* 

-H 

S 

.^-^ 

" 

-' 

o 

(D 

(D 

a> 



r_ 

~; 

2 

^ 

]3. 

■< 

— 

Cfi' 

'D 

— 

cr:     3 


BLOOD  SUPPLY  OF  THE  SCBOTUM.  411 

by  the  loose  connective  tissue  layer  with  the  scrotum  proper  and 
hence  is  readily  separable  from  the  latter. 

The  cremaster  is  a  voluntary  muscle  occurring  in  scattered,  arched 
bundles,  bound  together  by  thin  connective  tissue  laminie,  which  also 
form  the  sheaths  of  the  muscular  bundles.  These  bundles  lie  in  front 
of  (not  behindj  the  sac  formed  by  the  next  layer.  It  issnjjpHnl  hi/  the 
genital  branch  of  the  genitocrural  nerve.  Its  contraction  suddenly 
raises  the  testis  and  its  inner  coverings,  within  the  scrotal  j)()Ufh. 
The  cremasteric  reflex  is  the  reflex  contraction  of  this  muscle  following 
stimulation,  as  by  scratching,  of  the  skin  of  the  uj)])('r  and  anterior 
aspect  of  the  thigh,  which  is  supplied  by  the  crural  branch  of  this 
nerve.  The  muscle  becomes  lii/pertrop/iied  when  the  size  or  weight  of 
the  enclosed  mass  is  increased,  as  in  large  herniie,  etc.  According  to 
Toldt  its  contraction  favors  the  venous  circulation  within  the  scrotum 
and  helps  to  |)ress  out  the  contents  of  the  epididymis. 

The  infundibuliform  fascia  {iitfcmdl  sjjennaiic  fa.scia),  by  its  direct 
connection  with  the  lower  part  of  the  posterior  border  of  the  testis, 
anchors  the  latter  in  the  postero-inferior  part  of  the  scrotum,  so  that  it 
retains  this  position  when  the  cavity  of  the  tunica  vaginalis  is  filled 
with  the  fluid  of  a  hydrocele  or  a  hematocele.  Hence  we  pnndurc  n 
hydrocele  in  front  and  ai)ove,  to  be  out  of  reach  of  the  testis.  At  the 
point  of  attachment  of  the  testis  the  infundibuliform  fascia  is  also  ad- 
herent to  the  overlying  layers,  including  the  dartos  and  skin.  The 
adhesion  together  of  all  these  layers  forms  the  Hgdiin'iduin  .srroffdr. 

Loose  areolar  tissue,  continuous  with  the  suhperitoneal  connex'tirc  tis- 
sue, connects  the  infundibuliform  fascia  with  the  tunica  vaginalis  and 
binds  together  the  various  elements  of  the  spermatic  cord.  In  the  latter 
situation  it  contains  some  fat  and  is  the  seat  of  faff jf  fninors  of  fhf  cord^ 
which  occasionally  simulate  an  inguinal  hernia.  This  layer,  together 
with  the  infundibuliform  fascia,  is  known  as  the  fa.^cia  propria  of 
Cooper,  who  described  it  as  very  strong  in  large,  old  hernia?.  The 
parietal  layer  of  the  tunica  vaginalis  extends  for  halt"  an  inch  above  the 
level  of  the  testis,  forming  a  cul  de  sac  at  the  l)eginning  of  the  cord. 
Besides  the  (external)  cremaster,  two  collections  of  unstriped  muscle 
fibers  are  known  as  cremaster  muscles,  one  of  them  in  the  cord  (internal 
cremaster)  the  other  in  the  subserous  layer  (middle  cremaster).  One 
muscular  band  of  the  latter,  stronger  than  the  rest,  is  said  sometimes 
to  groove  a  hydrocele,  so  as  to  partly  divide  it. 

The  two  comjiosite  layers  of  the  coverings  of  the  testis  have  a 
separate  blood  supply,  with  anaj<tomoses  between  tin-  two  layers  and 
with  the  blood  supply  of  the  testis  at  the  scrotal  ligament  and  the 
base  of  the  scrotum.  The  anastomosis  between  the  two  halves 
of  the  scrotum  is  quite  free.  The  skin  an<l  dartos  are  supjdied  i)y  the 
pudic  ressels  (external  pudic  and  tlie  superficial  brancii  of  the  internal 
pudic),  the  envelopes  of  the  testicle  by  the  cremasteric  vessels.  Although 
the  scrotum  is  very  vascular  its  vitality  is  not  great,  so  that  it  may 
slough  from  severe  iuHainmatiou  or  pressure,  hence  sfrapjiing,  if  em- 
ployed at  all,  should  be  ;ij)|)lied  with  car*',  for  it  has  been  followed  by 


412  PELVIS  AND  PERINEUM. 

extensive  sloughing.  The  large,  superficial  and  often  tortuous  veins 
of  the  scrotum,  which  are  visible  through  the  skin,  should  be  avoided 
in  tapping  a  hydrocele.  They  end  in  the  long  saphenous  vein,  but 
communicate  with  the  spermatic  veins. 

The  lymphatics  of  the  scrotum  pass  to  the  inner  or  middle  group  of 
the  upper  set  of  superficial  inguinal  lymph  nodes.  These  nodes  are 
involved  in  diseases  of  the  testicle,  as  a  rule,  only  when  the  scrotum  is 
also  involved.  Elephantiasis,  a  disease  marked  by  great  hyperplasia  of 
connective  tissue  and  due  to  the  irritation  of  filaria  in  the  lymph 
vessels,  occurs  most  frequently  in  the  scrotum.  The  skin  and  dartos 
receive  their  nerve  supply  from  the  internal  pudic  and  small  sciatic 
nerves,  etc.;  the  ilioinguinal  does  not  supply  the  skin  of  the  scrotum. 
Embryologically  the  scrotum,  like  the  labia  majora,  is  formed  by  the 
genital  ridge,  the  two  sides  of  which  unite  together  mesially  to  form 
the  scrotum.  Failure  of  this  union  is  one  of  the  features  of  so-called 
hermaphroditism  in  certain  of  its  forms.  In  these  cases  the  ununited 
halves  of  the  scrotum  resemble  the  labia. 

The  Testis. 

Position. — (Fig.  97.)  The  testes  are  normally  situated  in  the  lower 
end  of  each  half  of  the  scrotal  pouch  where  they  are  suspended  by 
the  spermatic  cords  at  unequal  levels,  the  left  being  commonly  lower 
than  the  right,  owing  to  the  greater  length  of  the  left  spermatic  cord. 
This  enables  the  testes  to  avoid  pressure  from  one  another.  The 
testis  is  held  in  poxition  and  anchored  to  the  postero-inferior  part  of 
the  vaginal  sac  by  the  scrotal  ligament,  by  its  attachment  to  the  in- 
fundibuliform  fascia  along  the  lower  part  of  its  posterior  or  straighter 
border,  and  by  the  reflection  of  the  visceral  layer  of  the  tunica  vaginalis 
to  join  the  parietal  layer  postero-inferiorly.  Hence  when  the  vaginal 
sac  is  filled  with  fluid  as  in  hydrocele  or  hematocele  the  testis  occupies 
2i  postero-inferior  position  in  the  sac  and  we  can  safely  puncture  the  sac 
in  front  or  above.  In  about  one  case  in  twenty  the  testis  is  rotated 
on  its  vertical  axis  and  attached  antero-inferiorly  (inversion  of  the  testis) 
but  in  such  a  case  we  can  still  safely  tap  a  hydrocele  above  and  in 
front  or  at  the  side. 

Development  and  Descent.— In  early  foetal  life  the  testis  is  devel- 
oped internal  to  the  lower  end  of  the  kidney  at  the  level  of  the  second 
lumbar  vertebra,  hence  the  origin  of  the  spermatic  vessels  in  this 
region.  It  lies  behind  the  peritoneum,  or  with  a  short  mesentery  of 
peritoneum  (mesorchium),  and  to  its  lower  end  is  attached  a  bundle  of 
unstriped  muscle  fibers,  the  gubernaciduin  testis  (rudder  of  the  testis) 
whose  three-tailed  lower  end  is  attached  to  the  dartos  at  the  bottom 
of  the  scrotum  and  to  the  two  pillars  of  the  external  abdominal  ring. 
Beginning  to  descend  in  the  third  month  of  fcetal  life  it  reaches  the 
internal  ring  in  the  sixth  month.  Then,  preceded  by  a  pouch  of  peri- 
toneum from  this  part  (processus  vaginalis),  which  pushes  before  it  a 
sheath  from  each  of  the  layers  of  the  abdominal  wall  through  which  it 
passes,  the  testis  reaches  the  external   ring  at  the  eighth  month  and 


Till-:  TESTIS.  413 

the  bottom  of  the  scrotum  shortly  before  birth.  Hence  the  presence  of 
the  testis  m  the  scrotum  is  an  indication  of  the  maturity  of  a  male  fo-tus. 
The  caasc  of  this  "descent  of  tiie  testis"  is  uncertain,  but  it  is  probably 
partly  due  to  the  development  of  the  pelvic  and  lumbar  regions  which 
grow  upward  away  from  the  testis,  anchored  by  the  gubernaculuni, 
and  partly  to  the  contraction  or  shorteninjx  of  the  latter,  for  the  first 
cause  would  not  take  it  beyond  the  internal  rin^  at  mo^t. 

The  testis  may  be  arreted  in  ihi  descent  in  the  abdomen,  at  the  in- 
ternal ring,  in  the  inguinal  canal  or  just  outside  of  the  latter.  When 
the  testes  have  not  passed  the  external  ring  the  condition  is  called  m/jt- 
torcliisni  (normal  in  certain  animals,  elephants,  etc.)  or  monoervjitor- 
chism  when  only  one  testis  is  arrested.  A  testis  arrested  within  the 
canal  may,  and  one  at  the  external  ring  usually  does,  reach  the 
scrotum  at  or  before  puberty.  A  retained  testis  is  atrophic  and  is  said 
not  to  be  functionally  active  ;  hence  it  may  be  removed  without  ques- 
tion in  an  operati(»n  when  it  complicates  a  hernia.  It  is  also  said  to  Ije 
especially  liable  to  malignant  disease,  but  the  statement  is  sui)ported 
by  little  proof.  If  it  is  lodged  in  the  inguinal  canal  it  may  be  mis- 
taken for  and  predisjxjue.'i  to  a  hernia  and  is  subject  to  attacks  of  inflam- 
mation from  pressure  or  injury.  Such  an  inflamed  testis  mav  cause 
errors  in  diagnosis,  being  mistaken  for  abscess,  strangulated  hernia,  etc., 
unless  it  is  noticed  that  the  testis  of  that  side  is  wanting  in  the  scrotum. 
Again  the  testis  may  descend  into  the  groin  through  the  femoral  instead 
of  the  inguinal  canal,  or  it  may  wander  into  the  perineum  {edopion 
teMis). 

The  consistence  of  the  testis  is  jirui  and  elaMic,  more  so  when  the 
tubules  are  full  or  in  certain  diseases,  such  as  tuberculosis,  syphilis  or 
tumors,  less  so  before  puberty  or  when  atrophy  occurs  from  old  age  or 
otherwise.  The  consistence  is  normally  unifonn  and  the  surface  should 
be  smootJi,  so  that  when  nodules  or  localized  hardening  or  softening  occur 
the  testis  is  abnormal  or  diseased.  Partial  induration  of  the  epidid- 
ymis indicates  tuberculosis  or  a  chronic  following  an  acute  inflamma- 
tion (epididymitis),  which  is  said  to  be  nearly  always  in  the  tail  of  the 
organ. 

The  normal  size  (1^  inches  in  length,  1^  inches  in  depth  and  a  little 
less  than  1  inch  in  thickness)  and  the  normal  weight  (o  to  8  drachms) 
are  not  attained  until  after  puberty,  being  much  less  before  then.  If 
there  is  only  one  testis  (monorchism),  or  only  one  descended,  its  size 
and  weight  may  be  much  increased,  otherwise  such  increase  indicates 
a  pathological  condition. 

The  great  thickness  (1  mm.)  of  its  bluish-white  fibrous  covering, 
tunica  albuginea,  prevents  any  sudden  expansion  but  allows  a  grail ual 
increase  in  size,  as  in  tumors  or  chronic  inflammation.  This  accounts 
for  the  intense  pain  in  acute  orchitis,  tlue  to  ])rcssure  on  the  nerves  by 
the  products  of  inflammation  pent  up  within  the  unyielding  capsule. 
If  in  such  a  case  the  inflammation  is  purulent  and  an  opening  occurs 
in  the  tunica  albuginea  the  tension  of  the  iutlaininatorv  products  forces 
out  the  substance  of  the  testis  and  we  have  hernia  testis  which    mav 


414  PELVIS  AND  PERINEUM. 

even  go  on  until  all  the  testicular  substance  is  extruded  and  ouly 
granulation  tissue  remains.  This  condition  is  therefore  due  to  the  firm- 
ness of  the  fibrous  capsule.  The  pain  of  an  epididymitis  on  the  other 
hand  is  much  less,  as  the  fibrous  covering  of  the  epididymis  is  much 
less  thick  and  firm  and  more  elastic  and  yielding,  so  that  this  part 
may  swell  rapidly  and  extensively. 

The  chief  relations  of  the  testis  are  with  its  covering,  the  visceral 
layer  of  the  tunica  vaginalis,  with  the  epididymis  and  with  the  cord. 
The  testis  is  completely  covered  by  the  visceral  layer  of  the  tunica 
vaginalis,  except  along  its  posterior  border,  where  superiorly  the 
eiferent  tubules  pass  out  into  the  head  of  the  epididymis,  below  this 
the  vessels  enter  and  inferiorly  the  border  is  adherent  to  the  infundib- 
uliform  fascia  and  attached  to  the  scrotal  ligament.  Along  this  pos- 
terior border  the  visceral  layer  of  the  tunica  vaginalis  is  continuous 
with  the  parietal  layer  either  directly,  as  on  the  mesial  side,  or  after 
partly  covering  the  epididymis,  as  on  the  lateral  side. 

Normally  the  two  serous  layers  are  in  contact,  separated  by  only 
enough  fluid  to  moisten  or  lubricate  them.  An  increase  of  the  amount 
of  this  fluid,  which  may  reach  several  ounces  or  even  pints,  constitutes 
a  hydrocele  or,  if  the  fluid  is  largely  bloody,  a  Jueniatocele.  A  hydro- 
cele is  pear-shaped  with  the  small  end  above  and  is  commonly  trans- 
lucent, except  where  the  testis  lies,  the  normal  position  of  which  we 
have  seen  above. 

The  upper  tubular  portion  of  the  processus  vaginalis  usually  atro- 
phies soon  after  birth  to  a  mere  fibrous  thread  which  lies  among  the 
elements  of  the  spermatic  cord  and  which  we  can  sometimes  trace  from 
the  bottom  of  the  slight  depression  of  the  peritoneum  at  the  internal 
ring  to  the  upper  end  of  the  vaginal  pouch.  Sometimes  however  this 
upper  tubular  portion  remains  open  (see  p.  264),  in  whole  or  in  part. 
If  the  entire  "  processus  "  remains  open,  fluid  may  pass  into  it  from 
the  peritoneum,  or  may  be  returned  into  the  latter  by  pressure  or  pos- 
ture. It  would  be  unsafe  to  inject  irritant  fluids  into  such  a  congen- 
ital hydrocele,  owing  to  its  connection  with  the  peritoneal  cavity.  If 
the  processus  is  closed  above  and  below,  or  at  intervals,  and  is  open  be- 
tween, fluid  collecting  in  the  unclosed  portions  above  the  vaginal  pouch 
constitutes  an  encysted  hydrocele  of  the  cord,  either  monolocular  or 
multilocular.  Such  hydroceles,  like  the  processus  vaginalis  in  which 
they  are  formed,  lie  in  front  of  the  cord,  and  the  testis  can  be  plainly 
felt  below  the  swelling  if  there  is  no  vaginal  hydrocele  as  well.  An 
encysted  hydrocele  in  the  canal  of  Nuck,  which  is  occasionally  met  with, 
occurs  in  the  similar  process  of  peritoneum  in  the  female. 

The  epididymis  (Fig.  97)  r&s'fe  upon  the  posterior  border  and  over- 
laps the  back  of  the  external  surface  of  the  testis.  Its  enlarged  upper  end 
or  head,  globus  major,  projects  above  the  upper  extremity  of  the  testis, 
where  it  is  readily  felt.  It  is  intimately  connected  with  the  upper  end 
of  the  posterior  border  by  the  visceral  layer  of  the  tunica  vaginalis, 
which  covers  it,  and  by  the  vasa  efferentia  Avhich,  coiled  up  as  the 
coni  vasculosi,  form  the  great  bulk  of  the  globus  major.     Between  the 


THE  NERVE  SUPPLY  OF   THE  TESTIS.  415 

body  of  the  epididymis  and  the  outer  surface  of  the  testis  is  a  small 
fossa,  the  (I'Kjital  foam,  lined  by  the  tunica  vairinalis.  On  account  of 
its  mcM)-epi(li(lijiiiis^  connecting;  the  body  of  the  epididymis  with  the 
posterior  border  of  the  testis,  the  former  is  reatlily  movable  and  may 
be  pressed  away  from  the  testis  and  even  more  or  less  transversely 
placed,  after  stretching  of  this  serous  duplicature  in  cases  of  large 
hydrocele,  etc. 

Tlie  lower  and  somewhat  enlarged  end  or  ((d/,  globus  minor,  reaches 
nearly  to  the  lower  limit  of  the  posterior  border  of  the  testis,  to  which 
it  is  loosely  connected.  The  tunica  v(if/iit(ilis  leaves  uncovered  most 
of  the  tail,  the  posterior  part  of  the  inner  surface  of  the  bodv  and  the 
posterior  border  of  the  epididymis.  Along  the  latter  l)order  and  the 
mesial  part  of  the  posterior  border  of  the  testis  the  visceral  is  continuous 
with  the  parietal  layer  of  the  tunica  vaginalis  by  means  of  two  folds, 
between  which  the  vessels  pass  to  and  enter  the  posterior  borders  of 
each  organ.  The  globus  minor  is  continuous  with  the  vas  deferens, 
hence  inflammation  reaching  the  epididymis  jdong  tiie  vas  should  first 
affect  this  part.  From  its  greater  size  when  inflamed  and  swollen  the 
globus  major  is  much  the  most  prominent  part  in  epididymitis.  Most 
of  the  cases  of  so-called  swollen  testis  following  a  gonorrhreal  poste- 
rior urethritis,  the  ])assage  of  an  instrument,  etc.,  are  really  cases  of 
epidldymiiix,  the  testis  remaining  unaffected.  The  hard  and  much  en- 
larged epididymis  can  be  felt  behind,  above  and  more  or  less  external 
to  the  testis,  which  is  normal  in  size  and  consistence.  In  inversio 
testis  the  relative  positions  of  the  parts  eidarged  are  reversed.  Tu- 
berculosis commonly  attacks  primarily  and  often  exclusively  the  epi- 
didymis, syphilis  the  testis. 

The  arterial  supply  of  the  testis  is  from  the  spermatic  artery  with 
some  anastomotic  supply  from  the  artery  of  the  vas.  The  veins  enter 
the  spermatic  or  pampiniform  plexus.  When  varicosity  of  this  plexus 
occurs  before  adolescence,  or  when  it  exists  for  a  long  time,  it  may 
cause  atrophy  of  the  testis.  The  elevation  of  the  scrotum,  practiced 
in  all  inflammations  of  the  epididymis  and  the  testis,  acts  by  diminish- 
ing the  congestion  l)y  favoring  the  venous  but  not  the  arterial  circu- 
lation. The  lymphatics  enter  the  lumbar  nodes.  The  rare  instances 
where  affections  of  the  testis  involve  the  inguinal  nodes,  without  first 
involving  the  scrotal  coverings,  are  to  be  explained  by  lymphatic 
anastomoses  accompanying  the  vascular  anastomoses  which  we  know 
are  present  along  the  scrotal  ligament,  etc. 

The  Nerve  Supply. — The  association  of  the  spermatic  plexus,  ac- 
companying the  spermatic  artery  and  derived  from  the  renal  and  aortic 
plexuses,  with  the  abdominal  sympathetic  nerve  centcj-s  explains  (1) 
the  pain  in  the  testis  during  the  passage  of  a  renal  calculus  and  (2) 
the  nausea,  faintness  antl  collapse  or  syncope  which  result  fVttm  a  blow 
on  the  testis.  The  pahi  from  such  a  blow  extends  into  the  loins,  and 
pain  in  the  back  often  follows  the  injection  of  a  hydrocele  or  the  drag- 
ging of  a  tumor  of  the  testis.  The  sickening  pain  due  to  slight  pressure 
on  the  testis  is  so  characteristic  as  to  be  diagnosticallv  useful  in  detir- 


416  PELVIS  AND  PERINEUM. 

miniDg  the  presence  or  position  of  the  testis  in  a  swelling  in  the  inguinal 
region  or  scrotum.  Pressure  on  the  ovary  causes  a  somewhat  similar 
pain. 

Foetal  Remains. — Two  structures  go  under  the  name  of  hydatids  of 
Morgagni :  (1)  a  pediculated,  pear-shaped,  serous  sac  tilled  with  a  clear 
fluid,  attached  to  the  globus  major  and  not  always  present,  and  (2)  a 
constantly  present  sessile,  flattened  and  often  lobulated  structure,  con- 
taining in  its  center  a  canal  which  may  end  blindly  or  in  a  seminiferous 
canal.  The  sessile  hydatid  is  attached  to  the  upper  end  of  the  testis, 
in  front  of  the  globus  major,  and  represents  the  end  of  the  duct  of 
Midler ;  hence  it  is  homologous  with  the  fimbriated  extremity  of  the 
Fallopian  tube.  The  paradidymis  or  organ  of  Giraldes  in  adult  life 
consists  of  a  single  tubule,  probably  derived  from  the  Wolffian  body, 
which  is  blind  at  both  ends  or  connected  at  one  end  with  the  tube  of 
the  epididymis,  or  the  rete  testis.  It  appears  as  a  yellowish-white 
patch,  which  lies  outside  of  the  parietal  layer  of  the  tunica  vaginalis, 
on  the  lower  part  of  the  spermatic  cord,  in  front  of  the  spermatic  plexus 
and  posterior  to  the  globus  major. 

The  above  foetal  remains,  together  with  the  vas  aberrans,  are  of  prac- 
tical importance  because  they  may  give  rise  to  cystic  tumors,  including 
the  true  spermatic  cysts  containing  seminal  fluid.  The  latter  are  most 
often  formed  from  the  tube  of  the  epididymis,  especially  the  globus 
major.  The  above  cysts  may  project  free  into  the  cavity  of  the  tunica 
vaginalis. 

In  addition  to  tuberculosis  and  syphilis  the  testis  may  be  the  seat  of 
almost  any  new  growth  except  lipoma.  Sarcoma  and  chondroma  are 
particularly  common  and  tumors  of  the  testis,  like  those  of  the  paro- 
tid, are  very  liable  to  be  "  mixed,"  consisting  of  several  kinds  of  new 
growth.  New  growths  usually  spring  from  the  testis  proper,  seldom 
from  the  epididymis.  Removal  of  the  testes  diminishes  the  size  of  the 
prostate,  which  is  much  atrophied  in  eunuchs  ;  hence  the  employ- 
ment of  castration  in  the  treatment  of  hypertrophy  of  the  prostate, 
but  the  result  appears  to  be  only  temporary.  As  division  of  the  vas 
deferens  causes  atrophy  of  the  testis  it  has  also  been  employed  for  the 
same  purpose. 

The  spermatic  cord  consists  of  (1)  the  vas  deferens,  (2)  the  artery 
of  the  vas  deferens,  (3)  the  spermatic  artery,  (4)  sympathetic  nerves 
accompanying  the  arteries,  (5)  the  veins  accompanying  the  two  arteries, 
(G)  lymphatics  running  with  the  veins,  (7)  the  remains  of  the  pro- 
cessus vaginalis,  sometimes  present  and  (8)  the  internal  cremaster  fibers 
of  Heule  (see  p.  411).  All  these  structures  are  joined  together  by  a 
fatty  connective  tissue,  continuous  with  the  subperitoneal  tissue,  which 
may  give  origin  to  inguinal  or  scrotal  lipoma,  simulating  true  hernije. 

The  vas  deferens  lies  to  the  inner  side  and  behind  the  epididymis  at 
the  commencement  of  the  cord  and  bears  the  same  relative  position  to 
the  other  elements  of  the  cord  above,  where  its  hard  cord-like  feeling 
enables  it  to  be  readily  found  or  avoided  as  occasion  requires  (see  p. 
378).     In  castration  for  tuberculosis  or  tumor  of  the  testis,  etc.,  it  is 


THE  PERiyEUM.  417 

often  advisable  to  remove  the  cord  as  high  up  as  possible.  The  two 
arteries  and  their  accompanying  veins  require  ligation,  and  it  is  well 
to  ligate  them  separately  ratiier  than  to  ligate  the  cord  en  masse. 

The  cord  is  covered  by  the  same  layers  that  envelop  the  testis,  excjept 
the  tunica  vaginalis.  Superiorly  the  darton  is  rejj/acrd  hi/  superficial 
fascia,  between  which  and  the  skin  is  a  layer  of  subcutaneous  connec- 
tive tissue  and  fat.  In  reaching  the  cord,  as  in  operations  for  vari- 
cocele, branches  of  the  external  pudic,  cremasteric  and  superficial  epi- 
gastric arteries  are  likely  to  be  divided,  and  perhaps  some  branches  of 
the  superficial  perineal  arteries. 

The  veins  of  the  xpcnadtic  or  pampiniform  plexux  to  tii(,-  number  of 
five  or  six  lie  in  front  of  and  surround  the  spermatic  artery  and  i)resent 
frequent  anastomoses.  They  coalesce  to  three  or  four  plexiform  trunks 
in  tlie  inguinal  canal,  which  unite  into  two  and  finally  into  a  single  vein 
accomjianying  the  spermatic  artery  in  the  abdomen.  The  frequency 
of  varicosities  of  the  spermatic  veins,  or  varicocele,  is  explained  by 
their  length,  dependent  position,  few  and  imperfect  valves,  lack  of 
external  support  from  the  loose  surrounding  tissue,  pressure  in  their 
passage  through  the  inguinal  canal,  and  their  large  size  as  compared 
with  the  arteries,  which  renders  the  blood  current  sluggish.  The  aid 
furnished  to  many  veins  by  muscular  contraction  is  also  wanting. 
Those  with  a  normally  active  dartos  seldom  have  varicocele.  Several 
facts  may  be  given  to  explain  the  c/rerner  frefjneney  of  varicocele  o»  the 
lift  side,  /.  (?.,  the  greater  length  of  the  left  spermatic  cord,  the  pres- 
sure of  the  sigmoid  colon,  especially  in  ca.ses  of  constii)ation,  on  the 
left  spermatic  vein,  and  the  passage  of  the  latter  at  a  right  angle  into 
the  renal  vein,  while  the  right  vein  enters  the  cava  at  an  acute  angle. 
Conf/oiitdl  defcrfs  of  development  may  also  help  to  explain  the  above 
features  of  varicocele,  but  this  explanation  is  a  supposition  and  needs 
explanation  itself.  Varicocele  is  especially  an  affection  of  early  adult 
life  and  often  spontaneously  diminishes  with  the  diminution  of  sexual 
vigor  in  old  age.  Of  the  two  sets  of  veins  it  is  the  anterior  set,  or  the 
spermatic  plexus  accompanying  the  spermatic  artery,  which  is  prmci- 
pally  or  solely  involved. 

In  ligation  or  excision  of  these  veins  we  must  avoid  the  smaller  set 
accompanying  the  vas  deferens,  which  are  sufficient  to  carry  on  the 
venous  circulation.  The  Kpermaiic  artery  need  not  be  spared  from  among 
the  veins,  even  if  it  can  be,  for  the  anastomoses  with  the  artery  of  the 
vas  deferens  and  the  scrotal  arteries  are  sufficient  to  supply  the  testis. 
It  is  important  however  to  spare  the  f/cnitocrural  nerre,  which  supplies 
the  crcmaster  muscle,  fov  otherwise  this  muscle  would  l)e  i)aralyzed  and 
the  testis  would  hang  lower  than  before.  At  the  internal  alulominal 
ring  the  cord  is  formed  by  the  coming  together  of  the  vas  deferens  and 
its  vessels  with  the  spermatic  vessels. 

THE  PERINEUM. 

This    corresponds    to    the    outlet    of   the    i)elvis    ami   includes  the 
structures  between  the  skin  below  and  tlu'  pelvic  floor  above. 
27 


418  PELVIS  AXD  PERINEUM. 

Boundaries  and  Surface  Landmarks. — Its  bony  and  fibrous  boun- 
daries form  a  lozenge-shaped  figure  with  the  symphysis  in  front,  the 
coccyx  behind  and  the  ischiopubic  rami,  the  ischial  tuberosities  and 
the  great  sacrosciatic  ligaments  on  the  sides.  By  deep  pressure  we 
can  feel  the  bony  landmarks  and,  in  thin  subjects,  the  sciatic  liga- 
ments, beneath  the  inner  margins  of  the  glutei  maximi.  In  the  erect 
position  the  sciatic  ligaments  are  overlapped  by  the  internal  borders  of 
the  glutei  maximi  muscles,  but  not  in  the  sitting  or  lithotomy  posi- 
tion. The  bony  boundaries  are  seen  to  correspond  with  the  pelvic 
outlet  and  hence  vary  in  size  in  the  two  sexes  (see  p.  352).  In  the 
male  the  transverse  diameter  between  the  ischial  tuberosities,  usually 
3|^  inches,  is  sometimes  so  narrow  (2  inches)  as  to  interfere  with  lateral 
perineal  incisions.  The  average  antero-posterior  diameter  in  the  male 
is  3J  inches  but,  owing  to  the  convexity  of  the  parts,  the  surface 
measures  4  inches. 

Superficially  the  male  perineum  is  limited  by  the  scrotum  in  front, 
the  buttocks  behind  and  the  thighs  laterally.  With  the  thighs  together 
and  extended  the  perineum  appears  as  a  furrow  between  them,  but 
with  the  thighs  flexed  and  abducted  (lithotomy  position)  the  perineum 
appears  as  bounded  above.  The  median  raphe  of  the  skin  extends 
forward  from  the  anus  to  the  scrotum  and  thence  onto  the  penis.  As 
it  represents  the  embryonic  cutaneous  seam  of  the  two  halves  of  the 
perineum  no  vessels  cross  it,  hence  it  is  chosen  for  incisions  when 
possible.  It  is  well  to  remember  that  it  may  be  displaced  to  one  side 
by  adhesions. 

The  depth  of  the  perineum,  or  the  distance  between  the  surface  and 
the  pelvic  floor,  varies  individually  with  the  amount  of  subcutaneous 
fat,  and  locally  in  the  different  parts  of  the  area.  Thus  in  the  pos- 
terior and  lateral  parts  it  measures  2  to  3  inches,  but  less  than  1  inch 
anteriorly.  It  is  important  to  bear  in  mind  this  distance  in  operating 
on  the  pelvic  viscera  through  the  perineum,  as  in  opening  the  bladder, 
etc.  The  central  tendinous  point  of  the  perineum  lies  in  the  median 
line,  midway  between  the  center  of  the  anus  and  the  back  of  the 
scrotum,  and  1  inch  in  front  of  the  anus.  It  is  the  meeting  point  of 
the  bulbo-cavernosus,  superficial  transversus  perinei,  sphincter  ani  and 
a  few  fibers  of  the  levator  ani  muscles  and  the  superficial  and  deep 
perineal  fascia.  As  it  corresponds  to  the  center  of  the  posterior  edge  of 
the  deep  perineal  fascia  (triangular  ligament)  the  bulb  and  its  artery  are 
just  in  front  of  it.  Hence  in  lithotomy  and  similar  operations  the  inci- 
sion should  not  commence  much  in  front  of  this  point.  Corresponding 
to  the  bulb  and  the  perineal  ])ortion  of  the  corpus  spongiosum,  the 
surface  is  somewhat  elevated  in  the  median  line  in  front  of  the  central 
point,  and  this  elevation  may  serve  as  a  guide  to  the  position  of  the 
bulb. 

A  nearly  transverse  line  between  the  anterior  part  of  the  ischial 
tuberosities,  which  passes  through  the  "  central  point,"  divides  the 
region  into  an  anterior  or  urethral  triangle  (perineum  proper)  and  a 
posterior  or  anal  triangle. 


THE  PERINEAL  FASCIA. 


419 


The  "  perineum  proper  "  has  the  fonn  of  an  equihiteral  triangle, 
measuring  about  ',\\  inclics  on  all  sides.  The  haw  is  not  quite  straight, 
but  inclines  forward  from  either  side  to  the  middle  line,  at  the  central 
point  of  the  [)erineuin.  The  skin  is  freely  movable  on  the  subjacent 
parts  and  is  dark  and  thin,  readily  showing  any  extravasation  of  bhxjd 
beneath  it.  The  superficial  /(iijcr  of  the  sajjcrjiciril  fascia  contains  little 
or  no  fat  in  the  middle  line  but  more  fat  laterally  and  j)osteriorly,  where 
it  is  continuous  with  the  subcutaneous  fat  of  the  thighs,  of  the  ischio- 
rectal fossre  and  of  tiie  buttocks.  The  snjurjicial  li/injjliadcs  run  into 
the  middle  group  of  the  superior  inguinal  nodes. 

Apart  from  the  preceding  layers,  the  perineum  proper  co/<.s/W.v  af  a 
triangular  ledge  of  tissue,  composed  of  three  strong  layers  of  fascia 
stretching  nearly  horizontally  between  the  ischioj)ubic  rami  and  enclos- 
ing two  iuterfascial  spaces.  It  is  pierced  bij  the  urethra,  and  in  the 
female,  by  the  vagina. 

The  deep  or  membranous  layer  of  the  superficial  fascia,  the  fascia  of 
Colles  or  "  perineal  fascia,"  turns  uj)  l)ehind  the  superticial  transversus 

Fig.  99. 


Muscles  of  the  male  periiieutu.     (Gkhkism,  after  Testi'T.) 

perinei  muscle  to  join  the  base  of  the  triangular  ligament  and  thus  helps 
to  form  the  free  posterior  border  of  the  "  j»rrin((d  Ar/f/*."  It  thus  slnitM 
off'  a  sahfascial  space  (the  superlicial  jK-rineal  interspace)  from  the 
ischiorectal  fossa  behind  it.  This  -^pace  is  separatetl  from  the  thighs 
on  either  side  by  the  attachment  of  the  fascia  to  the  ischiopubic  rami, 
and  from  the  pelvis  by  the  attachment  of  the  triangular  ligament  to 


420  PELVIS  AND  PERINEUM. 

the  same  parts.  Hence  there  is  only  one  outlet  for  urine  extravasated 
into  this  space,  from  rupture  of  the  urethra  contained  within  it,  and 
that  is  forward  to  the  scrotum  and  penis  and  thence,  between  the 
symphysis  and  the  pubic  spines,  onto  the  abdomen  beneath  the  deep 
layer  of  the  superficial  fascia,  with  which  and  the  dartos  of  the  scrotum 
this  perineal  fascia  is  continuous.  (See  pp.  240  and  410.)  Ex- 
travasation of  urine  from  rupture  of  the  urethra  is  especially  liable  to 
occur  in  this  space,  beneath  the  perineal  fascia.  The  products  of  in- 
flammation and  other  fluid  collections  take  the  same  course. 

From  the  perineal  fascia  to  the  pelvic  floor  we  find  alternate  layers 
of  fascia  and  muscle,  etc.  Thus  in  tJie  suhfascial  sjjace,  beneath  the 
perineal  fascia  and  superficial  to  the  triangular  ligament,  we  find  the 
root  of  the  penis  and  its  muscles,  vessels  and  nerves,  together  with  the 
superficial  transversus  perinei  muscles  and  their  vessels  and  nerves. 
The  latter  muscles  lying  along  the  posterior  boundary  or  base  of  this 
region,  together  with  their  accompanying  vessels  and  nerves,  serve  as 
landmarks  and  are  liable  to  be  cut  into  or  across  in  lateral  incisions, 
as  in  lateral  lithotomy.  They  may  be  cut  with  impunity.  Forming 
the  root  of  the  penis  we  find  laterally  the  crura  penis  covered  by  the 
ischiocavernosi  muscles  and  attached  to  the  ischiopubic  rami,  and 
mesially  the  bulb  covered  by  the  bulbocavernosus.  The  space  is 
divided  by  the  bulbocavernosus  into  two  lateral  muscular  triangles, 
bounded  laterally  by  the  erectores  penis,  covering  the  crura  penis,  and 
posteriorly  by  the  two  superficial  transversus  perinei  muscles.  Some- 
times these  muscles  cover,  or  nearly  cover,  the  entire  area  and  again 
they  may  leave  a  considerable  gap  between  them,  showing  the  next 
deeper  layer,  the  triangular  ligament,  which  forms  the  roof  (often  called 
the  floor)  of  this  space. 

The  triangular  ligament  measures  about  an  inch  and  a  half  from 
the  subpubic  ligament  to  the  middle  of  its  base,  at  the  central  point  of 
the  perineum.  Its  principal  function  is  to  support  the  urethra  in  its 
course  beneath  the  symphysis.  Along  its  base  its  two  layers  fuse  with 
one  another  and  with  the  perineal  fascia  and  thereby  inclose  the  peri- 
neal interspaces  posteriorly,  and  form  the  free  border  of  the  perineal 
ledge.  This  border  is  incised  in  lateral  and  median  lithotomy  and  in 
the  perineal  operations  on  the  urethra,  bladder,  prostate,  etc.  The  two 
layers  of  the  triangular  ligament  separate  from  one  another  anteriorly 
to  inclose  the  wedge-shaped  deep  perineal  interspace. 

The  superficial  layer  of  the  triangular  ligament  is  pierced  by  the 
urethra  about  an  inch  behind  the  symphysis,  and  around  this  opening 
are  closely  attached  the  bulb  of  the  urethra  and  its  sheath,  while  the 
artery  of  the  bulb  pierces  it  on  either  side  of  the  urethral  opening.  It 
is  also  pierced  by  the  ducts  of  Cowper's  glands  on  each  side  of  and 
somewhat  behind  the  urethral  aperture,  and  by  the  rcsse/.s'  of  the  corpora 
cavernosa  more  anteriorly  and  close  to  the  lateral  attachment  of  the 
ligament.  Anteriorly  a  small  gap  is  left  between  this  layer  and  the 
subpubic  ligament  through  which  the  dorsal  vessels  and  nerves  of  the 
penis  pass  from  the  deep  to  the  superficial  perineal  interspace.     The 


THE  TRIANGULAR    LIGAMENT. 


421 


anterior  part  of  this  layer,  forming  the  posterior  boundary  of  the  aper- 
ture for  the  dorsal  vessels,  etc.,  is  somewhat  thickened  and  is  some- 
times called  the  preurethral  ligament  (JoesscI,  Waldeyer).  Luler- 
ally  this  layer  is  firmly  attached  to  the  ischiopubic  rami,  above  the 
attachment  of  the  perineal  fascia. 


Fi<;.  100. 


—SYMPHYSIS 


DEEP    LAYER    OF 
SUPERFICIAL 
FASCIA 


AREA    OF  CONTACT 

WITH    BULB.    RIGHT 

SIDE 

SUPERFICIAL    LAYER- 

OF    TRIANGULAR 

LIGAMENT 


DEEP    TRANSVERSE 
PERINEI    MUSCLE 
COWPER'S    GLAND 
WITHIN    muscle) 


Peep  layer  of  muscles  of  the  male  perineum.  On  the  left  side  of  the  -••ubject  the  superficial  layer  ot 
the  triangular  ligament  has  been  removed,  on  the  right  side  it  is  in  place  over  the  eoniiiressor  urethra; 
or  deep  transver.sus  periuei  muscle.  The  central  part  of  the  levator  ani  is  removeu,  exposing  the 
prostata,  etc.    (Testut.) 

The  deep  perineal  interspace,  between  the  two  lay  el's  of  the  triangu- 
lar ligament,  is  irc(I</c-,^/iajjc(l  with  the  apex  behind,  where  the  two 
layers  come  together.  It  contains  the  membranous  urethra  (see  p. 
399),  Cowper's  glands  (see  p.  399),  the  deep  transvcrsus  perinei  or 
compressor  urethra^  muscle,  the  internal  piidic  vessels,  nerves  and 
lymphatics  with  their  terminal  and  deep  branches  (/.  <■.,  to  the  bull),  the 
corpora  cavernosa  and  the  dorsum  of  the  jienis).  The  deep  transversus 
perinei  or  compressor  urethrae  muscle  is  a  V(»luntary  musch'  wli(>.>ie  inner 
circular  fibers  surround  the  membranous  urethra  and  are  eontinuous 
with  the  voluntary  fibers  in  front  of  the  j)rt)statie  uretlini.  The 
greater  part  of  its  fibers  pass  transversely  and  join  an  iiulistiuct 
median  raphO,  while  a  few  run  obliquely  and  sagittally.  They  com- 
press and  help  to  expel  the  contents  of  the  memi)ranous  urethra  and  of 
Cowper's  glands,  as  in  emission,  tliey  serve  as  the  external  sphincter 
vesicie  and  assist  in  the  erection  of  the  penis  by  compression  of  the 
veins  from  the  bulb,  the  corpora  cavernosa  and   the  dorsum  of  the 


422  PELVIS  AND  PERINEUM. 

penis,  which  pass  through  it.  Some  of  its  fibers  are  cut  in  lateral 
lithotomy  and,  to  a  less  extent,  in  many  median  perineal  operations. 

The  artery  of  the  bulb  runs  inward  in  this  interspace  about  half  an 
inch,  sometimes  less,  in  front  of  the  base  of  the  ligament  or  1|^  to  1|- 
inches  in  front  of  the  anus.  Hence  the  incision  in  lateral  lithotomy, 
etc.,  should  not  be  commenced  more  than  1}  inches  in  front  of  the  anus. 

The  superior  or  deep  layer  of  the  triangular  ligament  is  continuous 
with  the  obturator  fascia  along  the  upper  lip  of  the  inner  edge  of  the 
ischiopubic  rami,  where  both  these  fasciae  are  attached.  It  joins  the 
superficial  layer  anteriorly,  at  the  preurethral  ligament,  and  posteriorly 
along  the  posterior  edge  of  the  perineal  ledge.  Superiorly  it  forms 
the  floor  of  the  anterior  recess  of  the  ischiorectal  fossa,  on  either  side 
of  the  prostate.  The  apex  of  the  prostate  rests  upon  it  mesially,  and 
its  fibrous  capsule,  derived  from  the  rectovesical  fascia,  fuses  with  it. 
The  dorsal  vein  passes  between  it  and  the  subpubic  ligament,  the 
pudic  vessels  and  nerves  pierce  it.  Incision  through  the  posterior 
part  of  this  layer  on  either  side  opens  the  anterior  recess  of  the  ischio- 
rectal fossa,  and  then,  being  continued  more  deeply,  cuts  the  levator 
ani  with  the  anal  fascia  below  and  the  rectovesical  fascia  above  it, 
and  thus  enters  the  pelvic  cavity.  Median  incision  through  this  layer 
involves  the  prostate  above  it. 

In  lateral  lithotomy  the  2  to  3  inch  incision,  commenced  about  1^ 
inches  in  front  of  the  anus  and  a  little  to  the  left  of  the  median 
line  (to  avoid  the  bulb  and  its  artery),  is  carried  backward  and  out- 
ward to  a  point  somewhat  behind  and  external  to  the  mid-point  between 
the  anus  and  the  ischial  tuberosity.  Through  the  anterior  and  deeper 
part  of  the  incision  the  knife  is  carried  into  the  membranous  urethra 
and,  along  the  staff,  through  this  and  the  prostate  into  the  bladder. 
The  prostate  is  divided  obliquely  backwards  and  outwards.  We 
divide  the  skin ;  the  superficial  fasciae ;  the  transversus  perinei  muscle, 
vessels  and  nerve  ;  the  external  hemorrhoidal  vessels  and  nerves  ;  the 
base  of  the  triangular  ligament  and  compressor  urethrse  muscle ;  the 
meml)ranous  and  prostatic  urethrre  ;  the  anterior  fibers  of  the  levator 
ani ;  and  the  left  lateral  lobe  of  the  prostate. 

Parts  to  be  Avoided. — We  avoid  wounding  the  bulb  by  commencing 
the  incision  to  one  side  of  the  median  line  and  by  drawing  the  staff, 
and  with  it  the  bulb,  well  forward  under  the  pubes.  The  artery  of 
the  bulb  is  avoided  by  commencing  the  incision  not  more  than  1  \  inches 
in  front  of  the  anus.  The  rectum  is  easily  avoidable  if  it  is  not  dis- 
tended and  if  the  posterior  part  of  the  incision  is  not  carried  too  far 
back  or  too  near  the  median  line.  On  the  other  hand  the  pudic  vessels 
may  possibly,  though  not  probably,  be  wounded  if  the  incision  is  car- 
ried far  to  the  side.  If  the  incision  in  the  prostate  passes  beyond  the 
prostatic  capsule,  so  as  to  incise  the  rectovesical  fascia,  it  lays  open 
the  subperitoneal  tissue  of  the  pelvic  cavity,  the  ischiorectal  fossa 
and  the  neck  of  the  bladder  into  one  large  space.  This  is  most  likely 
to  occur  in  incising  the  vesical  outlet,  for  the  incision  into  the  lower  end 
of  the  gland  is  below  the  reflection  of  the  rectovesical  fascia  from  the 


MEDIAN  LITHOTOMY.  423 

pelvic  floor  onto  the  prostate.  If  the  jjro.-itdtic  inrl.tion  is  too  vertical  tlie 
left  ejaculatory  duct  is  in  danger  of  being  incised.  Tiic  j)rostatic  venous 
plexus  cannot  escape.  When  the  (irccsHorij  piulic  arkrt/  is  present,  it  in 
likely  to  be  injured  as  it  passes  forward  beneath  the  sides  of  the  pros- 
tate. In  (7/ /W/v'/i  lateral  lithotomy  or  any  form  of  jjcrineal  approach  to 
the  bladder  is  more  difficult  and  ol/jcctionablc,  because  tlic  pelvis,  pel- 
vic outlet  and  perineum  are  narrow  ;  the  bladder  is  liiglier  up,  uumt 
movable  and  less  strongly  attached,  and  the  prostate  is  rudimentary, 
so  that  more  of  the  vesical  outlet  itself  has  to  be  cut,  while  the  perito- 
neal pouch  descends  lower  and  may  be  wounded.  The  su|irapubic 
route,  on  the  other  hand,  is  easier  on  account  of  the  high  |)o>iti(jn  of 
the  bladder,  so  that  it  is  to  be  j)referred. 

In  median  lithotomy  or  cystotomy,  or  the  similar  incision  in  external 
urethrotomy,  perineal  section,  etc.,  the  parts  divided  are  (1)  the  skin  in 
the  median  ra})he  in  front  of  the  anus  for  1|  inches,  (2)  sujierficial 
fascia,  (3)  sphincter  ani,  (4)  the  central  point  of  the  perineum,  (oj  the 
base  of  the  triangular  ligament  and  of  ((3)  the  compressor  urethra?  muscle, 
(7)  the  membranous  urethra.  One  finger  in  the  rectum  to  guide  the 
upwardly  directed  knife  diminishes  the  risk  of  wounding  the  gut.  There 
is  less  cutting  and  more  dilating  in  median  cystotomy,  for  the  pro.s- 
tatic  urethra  and  vesical  outlet  are  only  dilated  and  not  cut.  The  ad- 
vantages of  the  median  operation  consist  in  (1)  little  bleeding,  owing 
to  the  slight  vascularity  of  the  raph6  and  median  line  of  the  perineum, 
and  (2)  little  danger  of  wounding  the  pelvic  fascia,  for  the  prostate 
and  vesical  outlet  are  stretched  and  not  cut.  It  is  an  excellent  opera- 
tion for  the  extraction  of  small  stones.  On  the  other  hand  it  pos- 
sesses disadvantages  in  (1)  the  danger  of  wounding  the  bulb,  which, 
however,  does  not  bleed  much  if  incised  in  the  exact  median  line,  and 
(2)  the  little  space  obtained  for  the  extraction  of  a  stone.  ^loreover  in 
children  it  is  contra in< J icated,  for,  owing  to  the  small  size  of  the  pros- 
tate and  vesical  outlet  and  the  slight  attachments  of  these  parts,  the 
bladder  may  be  torn  from  the  urethra  in  reaching  it  with  the  finger. 

When  we  wish  to  expose  fJie  prostate  or  seminal  re.^iclcs  other  j)erineal 
incisions  are  useful,  such  as  the  curved  transverse  incision  of  Zucker- 
kandl,  and  the  median  incision  encircling  the  anus  on  one  side,  as  in  v. 
Dittel's  lateral  prostatectomy.  The  greater  part  of  these  incisions  is  in 
the  ischiorectal  region.  They  aim  to  expose  the  ]>rostate  after  dividing 
the  anterior  fibers  of  the  levator  ani  muscle.  Then  the  seminal  vesi- 
cles may  be  exposed  by  separating  the  rectum  from  the  prostate  and 
bladder.  Zuckerkandl's  curved  incision  is  concave  toward  theix'ctum. 
In  all  perineal  oj)erations  on  the  male  bladder  it  should  be  remend>ered 
that  the  vesical  outlet  lies  "2}  to  ''>  inches  from  the  surface,  in  the  lith- 
otomy position.  But  this  distance  may  be  so  increased  in  some  cases 
of  prostatic  hypertrophy  as  to  make  the  perineal  route  to  tiie  bladder 
difficult  or  even  contraindicated. 

The  perineum  in  the  female  dilTers  from  that  in  the  mah-  in  the 
perforation  of  all  the  layers  in  the  median  line  by  the  vidvovaginnl 
passage  and  the  resulting  necvssary  ad:ii)tatiou  of  the  muscles.      It   is 


424  PELVIS  AND  PERINEU3L 

as  if  the  bulbocavernosi  and  the  bulb  were  cleft  in  two  halves  through 
their  median  raphe.  The  median  cleft  thus  formed  represents  the 
vulva  and  the  lower  end  of  the  vagina,  while  the  two  halves  of  the 
bulb  and  of  the  bulbocavernosi  represent  the  bulbi  vestibuli  and  the 
attenuated  compressor  or  sphincter  vaginte  respectively.  The  corpora 
cavernosa,  the  ischiocavernosi  and  the  superficial  transverse  perinei 
muscles  differ  only  in  their  smaller  size.  The  deep  transversus  perinei 
muscle,  like  the  two  layers  of  the  triangular  ligament,  is  of  course 
partly  cleft  by  the  vagina. 

The  "perineal  body,"  triaiu/ular  on  sagittal  section  and  bounded  in 
front  by  the  vulvovaginal  wall,  behind  by  the  anterior  rectal  wall  and 
below  by  the  cutaneous  surface  between  the  anus  and  the  posterior  vul- 
var commissure,  is  peculiar  to  the  female.  Besides  the  central  point  of 
the  perineum  and  the  muscles  that  meet  here  it  contains  a  mesh  work  of 
connective,  elastic  and  unstriped  muscle  tissue.  Thus  it  is  fitted  to 
stretch  in  parturition  as  it  does  to  a  remarkable  degree  during  the 
passage  of  the  head.  It  is  in  this  part  that  ruptures  of  the  perineum 
occur  during  labor.  Such  ruptures  may  be  superficial  or  they  may 
even  extend  entirely  through  into  the  rectum.  It  is  the  ischiorectal 
regions  and  the  portion  of  the  perineum  behind  the  vulva,  not  the 
firmer  anterior  part,  that  yield  most  in  parturition  so  as  to  allow  the 
passage  of  the  foetal  head.  The  cutaneous  base  of  the  perineal  body, 
between  the  anal  and  vaginal  orifices,  is  often  spoken  of  as  the  "  per- 
ineum." It  measures  1:^  inches  from  back  to  front  and  extends  later- 
ally between  the  two  ischial  tuberosities. 

The  Anal  Triangle  or  Ischiorectal  Region. 

The  superficial  fascia  contains  a  great  abundance  of  fat  which  fills 
the  two  pyramidal  ischiorectal  fossae,  lying  one  on  either  side  of  the 
anus.  (Fig.  107.)  These  fossse  are  hounded  above  and  internally  by 
the  obliquely  directed  levator  ani  and  coccygeus  muscles  (pelvic  floor), 
lined  beneath  by  the  ischiorectal  or  anal  fascia,  and  externally  by  the 
vertical  obturator  internus,  covered  by  the  obturator  fascia.  In  front 
each  fossa  ends  superficially  at  the  base  of  the  perineal  ledge,  but  more 
deeply  it  extends  forward,  nearly  as  far  as  the  symphysis,  as  the  ante- 
rior recess.  This  lies  on  top  of  the  perineal  ledge,  beneath  the  levator 
ani,  and  extends  forward  on  either  side  of  the  prostate,  between  it  and 
the  ischiopubic  rami  laterally.  Posteriorly  each  fossa  ends  superfici- 
ally along  the  great  sacrosciatic  ligament,  but  deeply  it  extends  back- 
ward a  variable  distance  toward  the  sacrum  between  the  ligament  and 
the  pelvic  floor,  as  the  posterior  recess. 

The  apex  of  the  fossa  is  along  the  white  line  on  the  obturator  fascia, 
or  a  little  below  it,  so  that  its  depth  is  about  two  inches  behind,  less  in 
front.  The  bcise  measures  an  inch  in  breadth  and  two  inches  from 
before  backward.  Crossing  this  space  about  its  center,  from  the  lateral 
wall  to  the  anus,  are  the  external  hemorrhoidal  vessels,  while  the  exter- 
nal angle  is  crossed  by  the  superficial  perineal  vessels  and  nerves  and 
along  the  posterior  border  runs  the  fourth  sacral  nerve.     The  presence 


"<v\^ 


PLATE    XLI  X 


FIG.    101. 


III  ^ 


OBTURATOR 
OR    PELVIC" 
FASCIA 


RECTO-VESI-. 
CAL     FASCIA 
ANAL   FASCIA 
OBTURATOR 
FASCIA 
INT.    PUOIC 
ARTERY 
INF.    HEMOR- 
RHOIDAL ART. 


^,\ 


Frontal    section    of   the     ischiorectal    space,  passing 
thi'ough  the  ischial  tuberosities.     iTillaux.i 


THE  ANAL  TRIANGLE  OR  ISCHIORECTAL  REGION.  425 

of  these  nerves,  especially  the  hemorrhoidal,  explains  the  great  pain 
which  usually  accompanies  ischiorectal  abscess.  In  opening  an  ischit)- 
rectal  abscess  the  structures  to  uroiil  are  tiie  pudic  and  external  hem- 
orrhoidal vessels  and  the  rectum.  We  incixc  in  a  line  radiating  from 
the  anus,  being  careful  not  to  inci.^e  too  deeply  near  the  anus,  on 
account  of  the  rectum,  or  too  far  toward  the  tuber  ischii,  where  the 
pudic  vessels  run  in  a  canal  (Alcock's)  in  the  obturator  fascia,  1  to  H 
inches  above  the  lower  end  of  the  tuberosity.  Early  inci.>.i(in  should 
be  practiced  to  prevent  the  inflammation  from  extending  throughout 
the  entire  fossa. 

IiiffaiiuiKttion  in  the  ischiorectal  fossa  is  fdcond  by  the  poor  bhifxl 
supply  of  the  contained  fat  and  by  the  tendency  to  congestion,  due  to 
the  dependent  position  and  lack  of  support  of  the  veins,  especially  in 
patients  suffering  from  venous  congestion  or  feeble  circulation,  such  as 
occurs  in  diseases  of  the  liver  (cirrhosis),  heart  and  lungs  (])hthisis). 
The  inflammation  is  also  favored  by  sitting  on  a  cold,  wet  seat,  by  injury 
and  by  the  passage  of  infection  throngh  the  rectal  wall,  preceded  per- 
haps by  an  nicer  of  the  lower  rectum.  Isc/iionvfal  «66vt.s-.s  hulfjr:<  ami 
tend'i  to  break  where  resistance  is  least,  /.  e.,  in  the  rectum  or  on  the 
skin  beside  the  anus  or  along  the  border  of  the  gluteus  maximus.  If 
it  perforates  both  on  the  skin  and  in  the  rectum  a  complete  fistula  in 
ano  results,  whose  internal  openinf/  is  usually  within  half  an  inch  of  the 
anus.  Owing  to  the  constant  dragging  apart  of  the  walls,  toward  the 
anus  by  the  sphincter  and  from  the  anus  \)y  the  levator  ani,  and  the 
reinfection  of  the  tract  from  the  rectum  spontaneous  cure  is  rare  and 
operation  is  required  (see  also  p.  3G4). 

Tiie  pad  of  fat  filling  the  ischiorectal  fossa  serves  as  an  elastic 
cushion  to  the  rectum  and  allows  its  descent  and  expansion  during 
defecation.  The  anal  portion  of  the  rectum  occupies  the  space  between 
these  two  fossae.  The  ischiorectal  fossa  is  opened  into  in  lateral  lith- 
otomy and  in  the  lateral  and  transversely  curved  incisions  to  explore 
the  prostate,  seminal  vesicles,  etc. 


CHAPTER   VI. 

THE    LOWER   EXTREMITY. 

The  lower  extremity  is  especially  adapted  to  bear  the  weiglit  of  the 
body  by  its  stronger  and  heavier  build  and  the  stronger  and  less  mov- 
able connection  of  its  first  segment,  the  thigh,  as  compared  with  the 
upper  extremity. 

THE   HIP. 

The  upper  segment,  the  region  of  the  hip,  will  be  studied  in  two 
sections,  (1)  a  posterior  or  gluteal  region,  the  buttocks,  and  (2)  an 
anterior  region  including  the  hip  joint. 

The  Posterior  or  Gluteal  Region,  the  Buttocks. 

This  region  is  bounded,  above  by  the  iliac  crest,  below  by  the  gluteal 
fold,  internally  by  the  sacrum  and  coccyx  and  externally  by  a  line 
from  the  anterior  superior  iliac  spine  to  the  great  trochanter. 

Surface  Markings  and  Landmarks. — The  iliac  crest  and  its  an- 
terior superior  spine  are  readily  felt.  The  posterior  superior  spine  is  less 
distinct,  especially  in  stout  subjects,  in  whom  its  position  is  indicated 
by  a  small  depression.  The  great  trochanter  is  a  prominent  landmark, 
especially  when  the  thigh  is  adducted  or  rotated  out.  In  very  stout 
subjects  a  slight  depression  marks  its  position.  Its  upper  border  is 
made  less  sharply  defined  by  the  tendon  of  the  gluteus  medius  which 
passes  over  it.  The  ischial  tuberosities  are  readily  felt  on  the  border- 
line between  the  buttocks  and  the  perineum.  When  the  thighs  are  ex- 
tended they  are  covered  by  the  fleshy  fibers  of  the  lower  borders  of  the 
glutei  maximi,  which  rise  above  them  when  the  thighs  are  flexed.  The 
sciatic  notch  can  only  be  felt  in  those  greatly  emaciated.  The  transverse 
gluteal  fold,  or  "fold  of  the  buttocks,"  is  neither  due  to  nor  does  it 
correspond  with  the  lower  border  of  the  gluteus  maximus,  which  is 
lower  and  more  oblique  than  the  fold.  The  fold  is  due  to  a  creasing  of 
the  skin  in  extension  of  the  hip.  In  flexion  of  the  hip  joint  the  but- 
tocks are  flattened  and  the  fold  becomes  oblique  and  is  finally  obliterated. 
Its  disappearance  in  early  hip  disease  is  a  useful  diagnostic  sign  and  is 
due  to  the  flexion  of  the  hip  joint  which  is  almost  constantly  present. 
The  change  in  the  fold  and  the  flattening  of  the  buttocks  are  not  due  to 
but  precede  the  wasting  of  the  gluteal  muscles,  which  exaggerates  these 
symptoms.  The  fjreat  sacro-sciatic  ligament  can  be  felt  on  deep  pressure 
beneath  the  lower  edge  of  the  gluteus  maximus.  The  tensor  vagince 
femoris  forms  a  slight  prominence  extending  from  a  point  just  outside  the 
anterior  superior  spine  downward  and  somewhat  backward  to  the  outer 
aspect  of  the  thigh  three  to  four  inches  below  the  great  trochanter.  , 

426 


POSITION  OF  THE   VESSELS  AXIJ  NERVES  427 

Topography. — The  posterior  superior  iliac  spine  is  on  a  level  with  the 
second  sacral  spine  and  the  center  of  the  sacro-iliac  joint.  In  this 
connection  it  may  l)e  noted  that  the  loireM  liinit  of  flie  spinal  membranes 
and  the  cerebrospinal  fluid  corresponds  to  the  third  sacral  spine  and 
the  upper  border  of  the  great  sacro-sciatic  notch.  The  sjiine  of  the 
ischium  is  on  a  level  with  the  first  piece  of  the  coccyx.  The  level  of 
the  upper  border  of  the  greed  trochanter  is  about  |  of  an  inch  below 
the  top  of  the  femoral  head,  at  or  just  below  the  center  of  the  hip 
joint,  and  nearly  on  a  level  with  the  pubic  sj/me.  The  atrophy  of  the 
gluteus  medius  and  minimus  muscles,  which  till  up  the  hollow  l>etween 
the  ilium  and  the  trochanter  and  render  the  prominence  of  the  latter 
comparatively  slight,  makes  the  trochanter  very  conspicuous. 

Nelaton's  line,  which  is  drawn  from  the  anterior  suj)erior  iliac 
spine  to  the  most  prominent  part  of  the  tuber  ischii,  normally  touches 
the  top  of  the  great  trochanter  and  crosses  the  center  of  the  acetabu- 
lum. Its  relation  to  the  trochanter  is  used  in  the  diagnosis  of  frac- 
tures of  the  neck  of  the  femur,  dislocations  of  the  hip  and  late  stages 
of  hip  joint  disease,  in  which  the  trochanter  is  displaced  uj>ward.  A 
still  more  convenient  line  for  this  ])urpose  is  Bryant's  line,  the  upper 
line  of  Bryant's  triangle.  This  line  is  drawn  vertically  backward  (in 
the  horizontal  posture)  from  the  anterior  superior  iliac  spine,  and  the 
distance  from  this  line  to  the  top  of  the  great  trochanter,  as  compared 
with  that  on  the  opposite  side,  indicates  any  displacement  upward  of 
the  trochanter. 

Position  of  the  Vessels  and  Nerves. — The  gluteal  artery  and  the 
nerve  just  below  it,  as  they  emerge  from  the  pelvis,  correspond  about 
to  the  middle  of  the  superior  border  of  the  sriatlr  notch.  This  point 
is  indicated  by  the  junction  of  the  upper  and  middle  thirds  of  a  line 
drawn  from  the  posterior  superior  iliac  spine  to  the  top  of  the  great 
trochanter,  when  the  thigh  is  slightly  flexed  and  rotated  inward.  In- 
cising in  this  line,  and  splitting  the  gluteus  maximus  muscle,  the  top  of 
the  sciatic  notch  is  felt  for  and  the  vessel  is  there  found,  if  its  ligature 
is  required.  The  scifdic  artery,  with  the  great  sciatic  nerve  external 
to  it,  emerges  from  the  sciatic  notch  at  a  point  coiresponding  to  the 
junction  of  the  middle  and  lower  thirds  of  a  line  drawn  from  the  |X)s- 
terior  superior  iliac  spine  to  the  outer  part  of  the  tul)er  ischii.  This 
line  crosses  the  posterior  inferior  iliac  spine  two  inches  below  the  upper 
end  and  the  ischial  spitie  four  inches  below.  The  latter  spine  is  crossed 
by  the  internal  pudic  artery  as  it  passes  from  the  great  to  the  small 
sacro-sciatic  foramen. 

The  great  sciatic  nerve,  emerging  from  the  pelvis  at  the  point  men- 
tioned, passes  thence  down  the  middle  of  the  back  of  the  thigh  in  a 
line  to  the  middle  of  the  popliteal  space,  and  crosseji  the  line  from  the 
tuber  ischii  to  the  outer  side  of  the  great  trochanter  at  the  junction  of 
its  middle  and  inner  thirds.  .1/  this  point  the  nerve  emerges  from 
beneath  the  lower  border  of  the  gluteus  maximus  and  is  m(>f<t  arcessible, 
being  onlv  covered  by  the  skin  and  fascia,  before  it  is  cro.ssed  by  the 
long  head  of  the  biceps.     It  may  be  cvposed  by  an  incision  having  this 


428  THE  LOWER  EXTREMITY. 

point  as  its  center  and  running  either  in  the  line  of  the  nerve  or  along 
the  lower  border  of  the  gluteus  maximus,  across  this  line.  The  latter 
muscle  is  retracted  laterally  and  the  nerve  is  found  as  a  white  cord  in 
the  loose  tissue  separating  this  muscle  from  the  hamstring  muscles. 

We  may  now  study  this  region  by  layers.  The  skin  is  thick  and 
firmly  connected  with  the  underlying  fascia,  so  that  it  is  not  movable. 
It  is  often  the  seat  of  furuncles,  which  are  very  painful,  for  its  t<ensi- 
bi/ity,  derived  from  a  number  of  nerves,^  is  almost  as  acute  as  that 
over  the  dorsum  of  the  hand.  The  subcutaneous  tissue  contains  a  large 
amount  of  fat,  to  which,  even  more  than  to  the  development  of  the  glu- 
teus maximus,  the  buttocks  owe  their  prominence  and  roundness.  This 
tissue  is  a  favorite  site  for  lij)omata  and  its  laxity  allows  large  eifusions 
of  pus  and  blood  to  occur. 

The  deep  fascia  is  attached  to  the  iliac  crest  above  and  the  sacrum 
and  coccyx  behind,  and  splits  to  inclose  the  gluteus  maximus  in  a 
sheath.  The  deep  layer  of  this  sheath  cov^ers  the  gluteus  medius, 
over  which  the  fascia  is  thicker  than  over  the  maximus,  especially  in 
front  of  the  latter.  The  glutei  medius  and  minimus  are  enclosed 
by  means  of  this  fascia  in  an  osseo-aponeurotic  space,  which  is  only 
open  below  toward  the  thigh  and  internally  at  the  sciatic  foramina. 
Effusions  of  blood  or  pus  pent  up  m  this  space  press  upon  the 
contained  nerves  and  explain  the  severe  pains  associated  with  them. 
Such  abscesses  may  extend  into  the  pelvis  or  a  pelvic  abscess  may  ex- 
tend into  this  space,  through  the  sacral  foramina.  Pus  or  blood  beneath 
the  deep  fascia  often  travels  for  some  distance  down  the  thigh  before 
it  can  reach  the  surface,  and  in  one  case,  related  by  Farabeuf,  the 
abscess  reached  the  ankle  before  it  broke.  Extravasations  of  blood 
beneath  the  fascia  may  fluctuate  and  be  mistaken  for  abscess,  as  they 
may  occur  without  any  discoloration  of  the  skin,  at  least  for  some  time, 
and  then  perhaps  at  some  distance  down  the  thigh.  The  deep  or  gluteal 
fascia  is  continuous  below  with  the  fascia  lata  of  the  thigh,  and  later- 
ally with  that  thickened  part  of  it  known,  from  its  attachments,  as  the 
iliotibial  band.  The  latter  serves  as  the  insertion  of  the  tensor  vaginae 
femoris  and  the  anterior  expanded  part  of  the  gluteus  maximus  ten- 
don, both  of  which  increase  the  thickness  of  the  band.  Across  the 
gap  between  the  iliac  crest  and  the  great  trochanter  this  baud  is 
tightly  stretched,  so  as  to  firmly  resist  the  pressure  of  the  fingers.  If, 
however,  the  trochanter  is  raised  this  band  is  relaxed,  a  fact  that  may 
be  useful  in  the   diagnosis  of  fractures  of  the   neck  of  the  femur,  etc. 

The  muscles  of  the  buttocks  may  be  divided  into  three  layers,  be- 
tween the  outer  of  which,  consisting  of  the  gluteus  maximus,  and  the 
middle,  comprising  the  gluteus  medius,  pyriformis,  obturator  internus 
and  quadratus,  lie  most  of  the  important  nerves  and  vessels.  Most 
incisions  in  this  region  are  made  parallel  with  the  fibers  of  the  gluteus 
maximus,  which  run  obliquely  downward  and  forward.     The  muscle 

'These  include  filaments  of  the  posterior  branches  of  the  lumbar  nerves,  some 
branches  of  the  sacral  nerves,  the  lateral  cutaneous  branch  of  the  last  thoracic  nerve, 
the  iliac  branch  of  the  iliohypogastric  nerve,  large  branches  of  the  small  sciatic 
nerve  and  filaments  of  the  external  cutaneous  nerve. 


PLATE    L. 


FIG.    102. 


POSTERIOR- 
SUPERIOR 
ILIAC    SPINE 


GLUTEAL    ARTERY 


SUP.    GLUTEAL 

NERVE 
INF.    GLUTEAL 

NERVE 
SCIATIC    ARTERY 
INT.     PUDIC 

ARTERY 
INT.     PUDIC 

NERVE 
SMALL    SCIATIC 

N  ERVE 
GREAT    SACRO-SCIATIC 

LIGAMENT 
GREAT    SCIATIC 
NERVE 


COMES    NERVI 
ISCHIADICI 
ARTERY 


Gluteal  region  of  left  side  after  removal  of  the  gluteus  maximus 
and  part  of  the  gluteus  medius.     (Joessel.j 


THE  GREAT  SCIATIC  NERVE.  429 

may  then  be  split  instead  of  cut.  The  rjlutcux  maximum  does  not  act  to 
maintain  the  erect  position,  but  only  in  rising  to  that  position,  in 
climbing  stairs,  etc.,  in  jumping,  and  in  carrying  heavy  weights  on  the 
back.  Hence  wJien  this  viHsc/e  /.s  paralyznl  the  patient  can  walk  on  a 
level  surface,  but  has  difficulty  in  rising  fr<jMi  a  si-at,  in  climl>ing  stairs, 
€tc.  In  parali/si.s  of  the  f//iif<'ns  mtdius  there  is  difficulty  in  maintain- 
ing the  erect  position  on  the  side  paralyzed. 

Of  the  bursae  in  this  region,  three  at  least  are  over  the  r/reater  trfj- 
chnnter,  separating  the  latter  from  each  of  the  three  gluteal  muscles. 
Only  that  between  the  trorlumter  and  the  f//iiteus  indxiians  is  of  much 
practical  importance  for  it  may  be  inflamed  and  render  painful  the 
movements  of  the  thigh.  Hence  in  the  inflammation  of  this  bursa,  the 
thigh  is  kept  flexed  and  adducted,  to  rest  the  muscle  whose  action  is  to 
extend  and  abduct  it.  A  bursa  over  the  tuber  isrhii  separates  that  proc- 
ess from  the  skin  and  subcutaneous  tissues,  in  the  sitting  posture.  (See 
pp.  345  and  42(3.)  Among  those  whose  occupation  requires  much  sitting 
this  bursa  is  often  inflamed  and,  when  inflamed,  it  is  known,  according 
to  circumstances,  as  "weaver's,"  "coachman's,"  "draymen's,"  or 
*'  lighterman's  "  bursa.  When  enlarged  it  may  press  upon  the  inferior 
pudeudal  nerve. 

Vessels. — The  gluteal  artery  is  usually  the  largest  of  this  region, 
being  of  the  size  of  the  ulnar,  hence  its  wounds  are  serious  and  have 
been  rapidly  fatal.  Wounds  of  this  artery  usually  involve  only  its 
branches,  for  the  portion  of  its  trunk  outside  of  the  pelvis  is  not 
longer  than  5  mm.  (Bouisson).  Hence  in  place  of  extra-pelvic  liejature 
of  the  vessel  for  aneurism,  ligation  of  the  internal  iliac  artery  is  usually 
performed.  Gluteal  aneurism  is  not  very  uncommon  and  comjiression 
of  the  internal  iliac  artery,  through  the  rectum,  has  been  tried  l>y  Dr. 
Sands  (Am.  Jour.  Med.  Sci.,  1881),  but  not  effectively.  If  the 
aneurism  involves  the  trunk  of  the  gluteal  artery,  which  runs,  near  its 
commencement,  between  the  lumbosacral  cord  and  the  first  sacral  nerve, 
nerve  symptoms  from  pressure  can  hardly  fail  to  occur.  The  (/hdeal 
and  sciatic  arteries  can  be  and  have  been  ligated  for  wounds,  through  an 
incision  in  the  buttocks  over  their  course.  (See  p.  427.)  The  size  of 
the  accompanying  veins  and  their  close  attachment  to  the  artery  increase 
the  difficulty  of  ligation  of  the  gluteal  artery.  There  are  several  cases 
known,  of  which  Henle  collected  six,  where  the  greatly  enlarged  seitdie 
artery,  running  alongside  of  the  sciatic  nerve,  took  the  place  of  the  femoral 
to  the  popliteal  space,  in  the  absence  of  the  femoral  artery.  The  sciatic 
artery  is  most  im])ortant  in  {ho  collateral  circulation  after  ligature  of  the 
femoral. 

The  superficial  lymphatics  of  the  buttocks  run  to  tlie  inguinal  noth's, 
the  deep  lymphatics  accompany  the  blood  vessels  to  the  nodes  lying 
near  the  pvriforinis,  and  thence  to  the  internal  iliac  nodes. 

The  great  sciatic  nerve,  after  emerging  from  the  ju'lvis  at  the  point 
indicated  above,  is  covered  by  the  gluteus  maxinms  and  lies  upon  the 
obturator  internus  and  the  quadratus  fenioris.  Neuralgia  in  this  nerve 
is  known  as  sciatica,  a  condition  due  to  a  variety  of  causes.      Within  the 


430  THE  LOWER  EXTREMITY. 

pelvis  aneurism  of  some  of  the  branches  of  the  internal  iliac  artery^ 
engorgement  of  some  of  the  pelvic  veins  lying  in  front  of  it  (Erb),  fecal 
accumulation  in  the  rectum,  the  fcetal  head  in  tedious  labors  and  various 
forms  of  pelvic  tumor  may  cause  sciatica  by  pressure.  I  have  lately 
seen  two  cases  where  a  tumor  of  the  postero-lateral  wall  of  the  pelvis, 
palpable  through  the  rectum,  caused  severe  sciatica.  Outside  of  the 
pelvis  it  is  near  enough  to  the  surface  to  be  affected  by  cold. 

Stretching  the  nerve  has  been  employed  in  the  treatment  of  this  con- 
dition. The  so-called  bloodless  or  dry  stretching  consists  in  forcibly 
flexing  the  hip  while  the  knee  is  kept  extended.  But  this  stretches 
not  only  the  nerve,  but  also  the  hamstring  muscles,  hence  wet  stretch- 
ing is  usually  employed,  the  nerve  being  first  exposed  by  an  incision 
(see  p.  427-8).  Trombetta  found  that  a  weight  of  183  pounds  was  re- 
quired to  break  the  great  sciatic  nerve,  representing  a  force  not  likely 
to  be  equalled  in  stretching.  But  the  nerve  can  be  torn  away  from  the 
soft  spinal  cord  by  a  force  not  at  all  sufficient  to  rupture  the  nerve, 
hence  care  must  be  exercised  in  making  traction  on  its  proximal  side. 

The  possibility  of  wounding  the  pelvic  viscera  through  the  sciatic 
foramina,  in  wounds  of  the  buttocks,  should  be  remembered.  Treves 
mentions  a  case  of  a  fiital  stab  wound  of  the  bladder  through  the  but- 
tock and  the  rectum  has  been  injured  in  like  manner.  We  operate 
upon  the  pelvic  viscera  through  the  great  sacrosciatic  foramen  after  divi- 
sion of  the  great  sacrosciatic  ligament,  with  or  without  removal  of  the 
coccyx  and  part  of  the  sacrum.  The  former  is  the  method  of  Kraske 
inresection  of  the  rectum. 

The  Anterior  or  Subinguinal  Region,  the  Region  of  Scarpa's 

Triangle. 

This  is  hounded  above  by  Poupart's  ligament,  below  by  a  line  12  to 
15  cm.  below  it,  on  a  level  with  the  gluteal  fold. 

Surface  Markings  and  Landmarks. — The  anterior  superior  iliac 
spine,  the  pubic  spine  and  Poupart's  ligament  are  most  important 
landmarks  and  readily  made  out  (see  p.  237-8).  The  sartorius  viuscle  is 
rendered  visible  or  palpable  when  the  thigh  is  raised  and  adducted, 
the  adductor  longus  when  it  is  adducted  in  spite  of  resistance.  The 
former  runs  obliquely  downward  and  inward  from  the  anterior  supe- 
rior iliac  spine,  the  latter  downward  and  outward  from  just  below  tiie 
pubic  spine,  hence  it  may  be  used  as  a  guide  to  that  spine  in  stout 
females.  These  two  muscles-,  crossing  12  to  15  cm.  below  Poupart's 
ligament  (10  cm.  in  muscular  subjects),  bound,  with  the  latter,  Scarpa's 
triangle.  This  triangle  may  appear  as  a  slight  hollow  below  the  fold 
of  the  groin.  In  thin  subjects  the  lower  group  (saphenous)  of  super- 
ficial lymph  nodes  can  be  felt  near  the  base  of  the  triangle;  if  enlarged 
they  are  readily  felt.  In  emaciated  subjects  a  prominence  sometimes 
appears  below  the  outer  half  of  Poupart's  ligament,  corresponding  to 
the  head  of  the  femur,  which  may  be  indistinctly  felt  in  extension  and 
rotation  outward  of  the  thigh. 


THE  SUPERFICIAL   FASCIA.  431 

Topography, — T\\v  jcinontl  r'my  lies  on  tlie  liorizoiital  line  connect- 
ing the  pubic  spine  and  the  top  of  the  great  trochanter,  one  inch 
from  the  former.  It  is  also  half  an  inch  internal  to  the  femoral 
artery  just  below  Poupart's  ligament.  'Hw  (uteni  \ii  a  little  internal 
to  the  middle  of  the  ligament,  or  midway  between  tlir  anterior  -npe- 
rior  iliac  spine  and  the  symphysis.  From  thence  the  line  of  the  artery 
is  drawn  to  the  adductor  tubercle,  or  the  back  of  the  inner  condyle, 
the  thigh  being  slightly  flexed  and  abducted.  The  uj)i)er  two  thirds 
of  this  line  corresponds  to  the  position  of  the  femoral  artery.  Its 
profituda  hrancli  is  given  off  about  1 },  inches  below  Poupart's  liga- 
ment and  the  artery  is  covered  by  the  sartorius  about  three  to  four 
inches  below  the  same  point.  The  femoral  vein  in  all  parts  of  its 
course  bears  a  relation  to  the  artery  just  the  reverse  of  the  sartorius 
muscle.  The  iia2*I)cnonf<  opening  lies  with  its  center  1),  inches  below  and 
also  external  to  the  pubic  spine,  where  its  position  is  sometimes  indi- 
cated by  a  slight  depression.  In  those  without  much  subcutaneous  fat 
the  long  saphenous  vein  can  be  seen  or  felt  running  up  to  the  saphenous 
opening.  This  vein  penetrates  the  cribriform  fascia  to  join  the  femoral 
vein  three  to  four  cm.  below  Poupart's  ligament.  Just  below  its  pas- 
sage through  the  fascia  it  sometimes  presents  a  dilatation,  which  might 
even  be  mistaken  for  a  femoral  hernia.  This  vein  and  its  tributaries 
are  often  the  seat  of  varices,  commonly  the  result  of  congenital  con- 
ditions. 

The  skin  is  thin  and,  below  Poupart's  ligament,  very  inovahlr  on 
account  of  its  loose  attachment.  Incision^'i  parallel  with  Poupart's 
ligament  do  not  gape,  hence  in  opening  abscesses  here  a  vertical  in- 
cision affords  better  drainage  by  allowing  separation  of  the  edges. 
After  burns  and  other  loss  of  substance  of  the  skin  of  this  region  the 
resulting  cicatrix  may  cause  flexion  of  the  hip  by  cicatricial  contraction. 
Supernumerary  mammary  glands  are  sometimes  found  in  this  region 
and  Treves  refers  to  a  case,  related  by  Jessieu,  of  a  woman  who  nursed 
her  child  from  a  breast  so  placed. 

The  superficial  fascia  is  usually  descrii)ed  in  tu-o  layers,  of  which 
the  superlicial  one  contains  the  subcutaneous  fat,  which  may  Ik*  so 
thick  as  to  make  operations  here  more  difficult.  This  tissue  is  a 
favorite  situation  for  fatty  tuinors  which  here  show  a  tendency  to  travel 
in  the  direction  of  gravity,  owing  to  the  looseness  of  the  tissue  aiul  of 
the  capside  of  the  tumor.  Between  the  two  layers  are  the  lower  or 
vertical  group  of  superficial  inguinal  nodes  [saphenous  nodes)  which 
receive  lymphatics  from  the  surface  of  the  lower  extremity,  the  perineum 
and  scrotum  and  sometimes  from  the  penis,  vulva,  urethra  and  the  lower 
part  of  the  vagina.  They  lie  over  the  saphenous  oitening.  Wlu-n 
these  glands  are  enlarged  or  the  seat  of  abscess,  as  often  occurs,  we 
should  look  to  the  parts  named  for  the  primary  lesion. 

The  cribriform  fascia  is  variously  described.  F-nglish  and  Ainerit-an 
authors,  for  the  most  l)art,  consider  it  as  belonging  to  the  do j)  layer 
of  the  superficial  fascia  and  as  covering  an  oval  noti-h  which  is  sup- 
posed to  intervene  between  the  anterior  or  iliac  jmrtion  and  the  (leej>er 


432  THE  LOWER  EXTREMITY. 

or  pectineal  portion  of  the  fascia  lata.  German  and  French  authors 
consider  it  as  o.  part  of  the  deep  fascia  (fascia  lata)  which  divides  below 
Poupart's  ligament  into  two  triangular  layers,  one  of  which  passes  in 
front  and  the  other  behind  the  femoral  vessels  to  unite  together  exter- 
nally in  front  of  the  iliopsoas,  internally  in  front  of  the  pectineus  and  be- 
low around  the  sheath  of  the  vessels,  3  cm.  below  Poupart's  ligament. 
In  either  case  the  cribriform  fascia  refers  to  the  fascia  covering  an  oval 
area,  the  saphenous  opening,  measuring  one  inch  in  its  long  or  vertical 
diameter.  This  fascia  is  thin  and  perforated  by  lymphatic  vessels, 
passing  from  the  superficial  to  the  deep  nodes,  and,  at  its  lower  end,  by 
the  long  saphenous  vein  as  it  passes  back  to  empty  into  the  femoral 
vein.  The  perforations  give  rise  to  the  name  cribriform  (sieve-like). 
The  femoral  canal  and  the  vascular  and  muscular  compartments  have 
been  already  referred  to  (see  pp.  269-70).  The  firm  deep  fascia  (fascia 
lata)  affects  the  extension  of  underlying  growths  and  abscesses  and  the 
opening  of  the  latter.  If  a  psoas  abscess  breaks  through  the  sheath 
of  the  iliopsoas  below  Poupart's  ligament  it  may  travel  in  the  line  of 
gravitv  far  down  the  thigh  before  it  opens  on  the  surface. 

AVithin  Scarpa's  triangle,  and  at  a  deeper  level,  is  a  second  triangle 
or  a  groove  between  the  iliopsoas  and  the  pectineus  {fossa  iliopectinea), 
in  which  lie  the  femoral  vessels.  The  iliopsoas  and  a  layer  of  fatty 
and  areolar  tissue  intervenes  between  the  vessels  and  the  hip  joint,  so 
that  in  amputation  or  excision  at  the  hip  joint  the  vessels  are  pro- 
tected from  injury,  in  freeing  the  head  of  the  bone.  Between  the  ilio- 
psoas and  the  thinnest  part  of  the  capsule  of  the  hip  is  a  bursa  which 
may  communicate  with  the  joint.  This  bursa  may  form  a  large 
tumor  in  this  region  when  chronically  inflamed.  Inflammation  of  this 
bursa  may  extend  to  the  hip  joint  or  vice  versa.  Sprain  or  even  par- 
tial rupture  of  the  adductor  group  of  muscles,  especially  the  adductor 
longus,  often  occurs  in  horseback  exercise.  The  lesion  is  usually 
close  to  their  pelvic  attachments.  It  may  be  accompanied  by  much 
effusion  of  blood,  and  may  be  followed  by  the  ossification  of  the  tendon 
of  the  adductor  longus  or  magnus,  to  the  extent  of  J  to  3  inches, 
a  condition  known  as  rider's  hone. 

Vessels. — The  femoral  artery  bisects  Scarpa's  triangle  from  its  base 
to  its  apex.  The  line  of  its  course  has  already  been  given.  Where  it 
crosses  the  pelvic  margin,  just  below  Poupart's  ligament  and  3|  cm. 
external  to  the  pubic  spine  (Richet),  it  is  only  separated  from  the  ilio- 
pectineal  eminence  by  a  thin  layer  of  the  iliopsoas.  Hence  compression 
of  the  vessel  is  here  most  easily  made  by  pressure  backward.  A  little 
lower  it  lies  in  front  of  the  head  of  the  femur,  from  which  it  is  sep- 
arated by  a  thicker  layer  of  the  iliopsoas.  Still  lower  it  lies  in  front  of 
and  internal  to  the  neck  of  the  femur  and  the  hip  capsule.  In  apply- 
ing pressure  to  the  artery  we  should  avoid  pressure  on  the  vein  because 
of  the  possible  danger  of  phlebitis.  The  anterior  crural  nerve  is  sep- 
arated from  the  artery  by  the  iliac  fascia,  so  that,  although  it  lies  only 
one  fourth  inch  external  to  it  just  below  Poupart's  ligament,  it  is  not  in 
danger  of  injury  by  pressure  in  compression  of  the  artery. 


PLATE    LI. 

FIG.  103. 


ILIAC    FASCIA 

ANTERIOR 
CRURAL 
NCRVC 


—FASCIA     LATA 

INTERNAL 

SAPHENOUS 

VEIN 
PROFUNDA 

FEMORIS 

ARTERy 


\^J- 


Region  of  Scarpa's  triangle,  left  side.     (Joessel.) 


FEMORAL  VESSELS.  433 

Tlie  length  of  the  common  femoral  artery^  or  tliat  part  above  the  j)ro- 
funda,  may  practically  be  taken  to  be  the  distance  between  the  origin 
of  the  deep  epigastric  and  the  profunda  femoris.  Altliough  this  is 
about  four  cm.  in  the  majority  of  cases,  Viguerie  found  that  in  about 
sixteen  per  cent,  the  distance  was  two  cm.  or  less.  Tlie  common 
femoral  may  therefore  be  so  short  as  to  render  ligature  difficult. 
Before  the  days  of  antisepsis  and  asepsis  the  nearness  of  a  large  col- 
lateral branch  was  most  important  in  the  ligature  of  large  arteries,  on 
account  of  the  danger  of  secondary  hemorrhage,  so  that  it  was  advised 
to  tie  the  external  iliac  instead  of  the  common  femoral,  where  ligature 
of  the  latter  was  indicated.  Nowadays  a  long  clot,  or  indeed  any  clot, 
betw^een  the  point  of  ligature  and  the  nearest  large  branch  is  not  con- 
sidered necessary,  so  that  this  objection  to  tying  the  common  femoral 
no  longer  holds  good.  However  the  femoral  is  eommonly  lif/afrd  at  the 
apex  of  Scarpa''^  trianf/lc,  unless  ligature  at  this  point  is  contraindi- 
cated.  Here  the  sartorius  crossing  it  serves  as  a  guide,  the  vein  is 
behind  and  somewhat  adherent,  the  saphenous  vein  is  internal  and  the 
long  saphenous  nerve  is  external.  The  femoral  artery,  from  its  suj)er- 
ficial  position  in  Scarpa's  triangle,  is  liable  to  he  rcounded.  Aneurism  is 
common  in  the  common  femoral,  for  the  artery  is  affected  by  the  move- 
ments of  the  hip,  is  exposed  to  injury  from  its  superficial  position  and 
it  bifurcates  into  two  large  trunks.  Arterio-venous  aneurisms  from 
wounds  may  also  occur  here. 

As  the  triljutarie.s  of  the  common  femoral  vein,  or  that  portion  of  the 
femoral  vein  above  the  entrance  of  the  long  saphenous  vein,  are  pro- 
vided with  valves  which  should  normally  prevent  the  backward  flow 
from  the  femoral  to  the  tributaries  of  the  pelvic  veins  anastomosing  with 
them,  it  would  appear  as  if  the  femoral  vein  was  the  only  outlet  to  the 
pelvis  of  the  blood  of  the  lower  extremity.  From  this  premise  it  was 
argued  that  the  ligature  of  the  common  femoral  vein  alone  would  lead  to 
gangrene,  and  should  not  i)e  done  without  simultaneous  ligature  of  the 
artery,  to  prevent  the  inflow  of  too  much  blood  into  the  limb.  In  fact 
many  ligated  the  artery  only  in  case  of  a  wound  of  the  vein.  But  many 
cases  of  isolated  ligature  of  the  common  femoral  vein  are  on  record 
without  gangrene  resulting.  In  fact  Braun  found  from  statistics  that 
the  ligature  of  the  common  femoral  vein  alone  was  less  often  followed 
by  gangrene  of  the  extremity  than  either  ligtiture  of  the  artery  alone 
or  of  both  artery  and  vein.  Experimentally  P)raun  found  that  in 
85  per  cent,  the  valves  of  the  anastomosing  tributaries  gave  way 
before  a  pressure  of  180  mm.  of  mercury.  The  greater  the  pressure 
the  better  the  chance  of  venous  collateral  circulation,  hence  the  artery 
should  not  be  ligated,  unless  necessary,  in  order  to  increase  the  pres- 
sure in  the  veins.  According  to  Richet  and  Verneuil  the  coUatonil 
circulation  occurs  especially  between  the  external  pudic  veins  and  tlie 
veins  of  the  pelvis  and  between  the  internal  circumflex  veins  and  the 
veins  of  the  buttocks.  It  is  (piito  probable  that  there  are  more  col- 
lateral anastomoses  than  are  known  and  that  the  valves  are  often 
wanting  or  insufficient. 
28 


434  THE  LOWER  EXTREMITY. 

Phlebitis  involves  the  femoral  vein  not  infrequently  as  a  sequela  of 
typhoid  and  other  fevers,  as  well  as  of  operations  like  appendectomy, 
hysterectomy,  etc.,  even  when  they  are  apparently  aseptic.  The  cause 
is  probably  a  slight  degree  of  infection,  a  sluggish  circulation  and  the 
dependent  position  of  the  part  in  bed ;  and  the  result  is  pain,  followed 
by  swelling  of  the  leg. 

The  deep  lymphatic  nodes,  three  to  four  in  number,  lie  in  front  of 
and  internal  to  the  femoral  vein,  and  one  of  them  lies  upon  the  septum 
crurale  (see  p.  271).  The  pathology  of  elephantiasis,  which  is  more 
common  in  the  lower  extremity  than  elsewhere,  is  concerned  with  the 
lymphatics  of  this  region  which  are  obstructed  by  the  filaria  sanguinis 
hominis,  a  small  thread  worm.  This  obstruction  leads  to  an  enor- 
mous increase  in  size  of  the  extremity  from  distension  of  the  lymph 
channels  and  hypertrophy  of  the  connective  tissue. 

The  crural  branch  of  the  genitocrural  nerve  gives  sensory  filaments 
to  the  skin  over  Scarpa's  triangle,  the  irritation  of  which  causes  the 
"  cremasteric  reflex,"  which  consists  of  the  retraction  of  the  testis  and 
is  due  to  the  contraction  of  the  cremaster  muscle,  which  is  supplied  by 
the  genital  branch  of  this  nerve.  This  reflex  is  most  marked  in  chil- 
dren and  young  adults  and  indicates  the  condition  of  the  second  lum- 
bar segment  of  the  cord,  which  is  the  spinal  center  of  this  nerve. 

The  Hip  Joint. 

Topography. —  The  center  of  the  acetabulum  lies  in  Nelaton's  line,  on 
or  just  above  the  level  of  the  top  of  the  great  trochanter  and,  in  the 
upright  position,  a  little  below  the  level  of  the  upper  border  of  the 
symphysis.  The  tuber  ischii  lies  below  and  behind  it.  The  center  of 
the  head  of  the  femur  lies  about  two  inches  directly  below  the  anterior 
inferior  iliac  spine,  and  on  a  line  drawn  at  right  angles  to  the  center 
of  the  line  connecting  the  anterior  superior  iliac  spine  and  the  spine  of 
the  pubis,  about  two  inches  from  the  latter  line.  At  this  point  it  may 
sometimes  be  felt  in  emaciated  subjects.  The  top  of  the  head  of  the 
femur  is  f  inch  above  the  upper  border  of  the  great  trochanter.  The 
portion  of  the  great  trochanter  which  is  most  external  and  subcutaneous 
is  about  one  inch  below  its  upper  margin.  According  to  Hueter  the 
top  of  the  great  trochanter  is  relatively  higher  in  the  child  owing  to 
the  relative  shortness  of  the  neck. 

The  cartilage-covered  portion  of  the  femoral  head  is  somewhat  more 
than  a  hemisphere  and  has  a  radius  of  about  an  inch.  The  superior  and 
anterior  aspects  of  the  head  are  rather  more  covered  by  cartilage  than 
the  inferior  and  posterior.  The  depression  for  the  ligamentum  teres, 
behind  and  below  the  center  of  the  head,  is  a  little  below  the  point 
reached  by  the  prolongation  of  the  axis  of  the  neck.  The  articular 
or  cartilage-covered  surface  of  the  acetabulum  is  horseshoe-shaped,  1 
to  I  inch  in  width,  and  encloses  a  thin  non-articular  area  of  bone. 
The  latter  area  is  seldom  fractured,  for,  in  spite  of  its  thinness,  it 
does  not  receive  the  direct  impact  of  the  femoral  head,  on  account  of 


THE  HIP  JOIST. 


435 


the  shape  of  the  cavity.  According  to  Tillaux,  one  of  the  rhief 
functions  of  the  /if/(uneiifiiin  teres,  as  indicated  by  its  oblique  direction 
upward  and  inu-drd  to  tiie  head  of  the  femur,  is  to  arrest  the  pres.sure 
of  the  head  against  the  bottom  of  the  acetabuhmi.  In  rare  cases  suj)- 
puration  in  the  hip  joint  may  reacli  the  pelvis,  or  vice  versa,  bv  per- 
forating this  thin  area.  Before  tiie  eighteenth  year,  when  the  Y- 
shaped  cartUxujc  uniting  the  three  bones  whicli  meet  in  the  acetabuhira 
has  ossified,  perforation  may  occur  through  the  cartilage  and  the  awtab- 
ulum  may  be  broken  up  into  its  three  parts  by  disease.  The  bone  just 
above  the  acetabulum  is  very  thick  to  transmit  the  weight  of  the  trunk 
to  the  head  of  the  femur  (see  p.  348).  The  acetabulum  measures  'M)- 
35  mm.  in  depth  in  the  male,  less  in  the  female,  and  it  averages  5  cm. 
in  diameter  at  its  rim. 

Fig.  104. 


THINAREA   OFCAPSULE 

ON  WHICH    RESTS  THE 

BURSA    BENEATH    THE 

PSOAS 

PUBO-FEMORAL 

BAND 


TENDON    OF    REC- 
TUS   FEMORIS 


SUPERFICIAL  PART  OF 
ILIO-FEMORAL  BAND 
DISSECTED    AWAY 


ILIO-FEMORAL 


W  BAN 


Ligaments  of  the  hip  joint  of  the  left  side.     Anicricir  view.     (.Toessel.) 


The  strenf/th  of  the  hip  joint  dcijcitds  not  only  upon  the  shape  of  the 
bones  but  also  on  the  strength  of  the  connecting  ligaments  and  of  the 
surrounding  muscles  and  tendons.  The  strongest  part  of  the  capsule 
is  the  iliofemoral  band  or  Y  ligament,  whit-h  is  a  (piartcr  of  an  iiu-h  thick 
in  its  thickest  part  :ind  is  one  of  the  strongest  ligaments  of  the  bodv, 
being  capable  of  sustaining  a  strain  of  from  250  to  750  pounds  (Bige- 
low).  This  ligament  is  of  the  utmost  iuiportonce  In  dlsloratlons  of  the 
hip  joint  in  determining  both  the  position  of  the  limb  and  the  metliods 
of  reduction  by  manipulation  and  it  is  almost  never  torn.  The 
thinnest  and  irvifkcst  parts  of  the  vdpsu/e  are  on  either  side  of  the  pubo- 
femoral band.     The  thin  part  in  front  of  it  is  just  below  and  external 


436  THE  LOWER  EXTREMITY. 

to  the  iliopubic  eminence,  between  the  pubo-  and  iliofemoral  bauds,  and 
under  the  bursa  between  the  iliopsoas  and  the  joint  capsule.  There  is 
often  a  defect  in  this  thin  area,  so  that  the  bursa  and  the  joint  are  only- 
separated  by  synovial  membrane,  and  the  latter  is  also  sometimes  want- 
ing, making  a  direct  communication  between  the  two.  This  explains 
how  pus  in  the  joint  can  readily  perforate  or  extend  into  the  bursa  and 
S(j  come  to  lie  beneath  the  iliopsoas,  and  also  how  a  psoas  abscess  may 
occasionally  invade  the  joint.  The  tliin  area  bcliind  is  internal  to  the 
pubofemoral  band  and  at  the  posterior  and  lower  part  of  the  capsule. 
The  rupture  of  the  capsule  in  dislocation  of  the  hip  occurs  most  com- 
monly in  this  area.  When  the  joint  is  distended  with  effusion  the 
swelling  naturally  first  appears  at  these  two  thin  areas,  which  are  acces- 
sible to  pressure  and  correspond  to  the  most  marked  and  earliest 
tenderness. 

The  cotyloid  ligament  closely  embraces  the  head  of  the  femur  ex- 
ternal to  its  greatest  diameter  and,  by  preventing  the  entrance  of  air, 
holds  the  head  in  place  by  atmospheric  pressure,  when  the  capsule  and 
the  surrounding  muscles  are  divided.  Hence  in  excision  or  amputation 
of  the  hip  joint  this  ligament  is  divided  to  permit  the  removal  of  the 
head  from  the  socket.  Opening  an  abscess  connected  with  the  hip 
joint  does  not  increase  the  risk  of  pathological  dislocation,  unless  the 
abscess  also  communicates  with  the  space  between  the  head  and  the 
socket  and  has  destroyed  the  continuity  of  the  cotyloid  ligament  or  has 
eroded  the  head  embraced  by  it.  The  cotyloid  ligament  levels  over  the 
slight  depressions  of  the  margin  of  the  acetabulum,  where  the  pubis 
joins  the  ilium  and  the  latter  the  ischium.  Hence  these  slight  depres- 
sions can  have  no  influence  upon  the  mechanism  of  dislocation  as 
supposed  by  Malgaigne. 

No  definite  function  is  agreed  upon  for  the  ligamentum  teres.  Ac- 
cording to  Hyrtl,  the  vessels  which  it  was  supposed  to  carry  to  the 
head  of  the  femur  do  not  reach  the  latter,  but  bend  around  into  the 
efferent  veins.  Although  put  on  the  stretch  by  adduction  and  outward 
rotation  these  movements  are  limited  by  other  and  stronger  ligaments 
(see  p.  437).  Surgically  it  must  first  be  destroyed  or  cut  before  the 
head  can  be  removed  from  the  socket.  Unless  abnormally  long  it  is 
always  torn  in  dislocations,  except  in  the  congenital  variety  in  which  it 
is  lengthened,  even  to  6  or  8  cm. 

Owing  to  the  direction  of  the  neck  of  the  femur  the  two  most  impor- 
tant movements  of  the  hip,  flexion  and  extension,  cause  a  rotation  of 
the  head  in  the  socket  without  its  projecting  far  from  the  latter  and 
thus  pressing  unequally  upon  the  capsule.  Hence  the  hip  joint  is  very 
secure  in  these  two  principal  movements.  In  the  other  movements  the 
head  projects  from  the  socket  on  the  side  opposite  to  that  toward  which 
the  movement  takes  place.  As  one  of  the  factors  of  rujjture  of  the 
capsule  is  pressure  of  a  projecting  portion  of  the  head  against  a  weak 
part  of  the  tense  capsule,  dislocation  is  not  likely  to  occur  during  simple 
flexion,  although  the  thin  posterior  part  of  the  capsule  is  then  tense, 
but  in  flexion  combined  with  adduction,  abduction  or  rotation.     In 


niP  DISEASE  OR   COXITIS.  437 

rotation  also  the  head  projectis  frum  the  socket,  for  the  axis  of  rotation 
does  not  coincide  with  that  of  the  neck. 

The  movements  of  the  hip  joint  are  liinifed  «.s  foHoirx:  extensicjn  by 
the  iliofemoral  band  ;  flexion  by  contact  of  the  soft  parts  in  tiie  j^roin, 
when  the  knee  is  bent,  and  by  tl>e  hamstring  muscles,  when  the  knee 
is  extended  ;  abduction  by  the  pubofemoral  band  ;  adduction  by  the 
outer  part  of  the  iliofemoral  band  and  capsule ;  rotation  outward  by 
the  iliofemoral  band  (its  inner  part  during  extension,  its  outer  ])art 
during  flexion);  rotation  inward  by  the  ischiofemoral  l)and,  (hiring 
flexion,  by  the  iliofemoral  band,  during  extension. 

The  hip  joint,  owing  to  its  deep  position  and  thick  covering  of  soft 
parts,  is  not  very  liable  to  attacks  o^  acute  infammafion  from  injury,  ex- 
posure, etc,  to  which  otlier  joints  are  liable.  It  seems  however  par- 
ticularly su.scepfihfe  to  chronic  iiijinininatioii.  Thus  it  is  a  favorite  site 
for  senile  rheumatoid  arthritis  in  which  the  cartilages  and  bony  surfaces 
are  eroded,  the  latter  eburnated  and  osteophytic  processes  developed 
around  the  joint  surfaces,  so  as  to  impede  its  movements. 

"Hip  Disease"  or  Coxitis. — Still  more  common  and  important  is 
the  occurrence  of  tubercular  inflammation  of  the  joint  known  as  hip 
disease  or  coxitis.  In  the  great  majority  of  cases  it  commences  in 
early  childhood.  In  this  condition  the  limh  assumes  certain  character- 
istic positions  at  various  stages.  In  the  first  stage  the  thigh  is  jicved, 
abducted  and  slightly  everted.  This  is  the  poxition  of  greateM  ease  and  is 
that  assumed  by  the  limb  when  fluid  is  forcibly  injected  into  the  joint 
as  in  it  the  joint  holds  the  most  fluid.  Hence  it  depends  upon  the 
eifusion  and  is  assumed  to  diminish  the  tension  and  thereby  relieve  the 
pain.  This  is  borne  out  by  the  fact  that,  in  cases  where  the  primary 
lesion  is  within  the  bone  and  there  is  no  eifusion  at  first  into  the  joint, 
this  first  position  of  flexion,  abduction  and  eversion,  is  not  observed, 
but  the  limb  becomes  at  once  adducted  and  rotated  in.  According  to 
some  this  position,  as  well  as  that  assumed  later  on,  is  due  to  the  reflex 
contraction  of  muscles  which  are  supplied  by  branches  of  the  same 
nerves  that  supply  the  joint,  /.  e.,  anterior  crural,  obturattir  and 
branches  of  the  sacral  plexus.  The  jle.red  thigh  is  made  to  appear 
straight  by  lordosis,  or  the  extension  of  the  thoracicolumbar  spine, 
whicii  tilts  backward  the  pelvis  and  therewith  the  femur  without  any 
movement  in  the  sensitive  diseased  joint.  The  patient  can  thus  stand 
or  lie  with  both  limbs  apparently  straight.  The  lordosis  can  be  detected 
by  moving  the  thigh  when  the  ])atient  lies  on  a  table.  When  the  thigh 
is  flexed  to  the  angle  at  which  it  is  fixed  (in  flexion)  the  lordosis  dis- 
appears, in  other  words  when  the  lordosis  is  made  to  disajijH'ar  the 
degree  of  flexion  is  shown.  If  we  continue  to  ilex  the  thigh  the  spine 
becomes  still  more  straightened,  so  as  to  .squeeze  the  hand  placed 
between  it  and  the  table.  When  the  thigh  is  again  exti'uded  the  lor- 
dosis can  be  felt  to  return. 

To  overcome  the  abduction  and  to  restore  the  parallelism  of  the  limbs, 
without  movement  in  the  diseased  and  painful  joint,  the  inlvis  l,s  tilted 
down  on  the  diseased  side  and  up  on  the  sound  side.     This  would  ab- 


438  THE  LOWER   EXTREMITY. 

duct  the  sound  limb  which  is  corrected  by  its  being  adducted.  Owing 
to  the  tilting  of  the  pelv'is  the  diseased  side  is  lowered  and  appears 
lengthened,  the  sound  side  appears  shortened  (Fig.  77).  If  the  tilting 
of  the  pelvis  be  corrected  the  limb  on  the  side  of  the  disease  is  found 
abducted,  the  sound  limb  adducted.  Hence  on  measurement  from  the 
anterior  superior  iliac  spine  (see  page  352)  we  get  measured  shortening 
on  the  diseased  side,  though  at  this  stage  there  is  no  difference  in  length. 
The  measured  shortening  is  also  increased  by  the  flexion.  Thus  we 
get  apparent  lengthening,  measured  shortening  and  real  equality  of  the 
limb  on  the  affected  side  as  compared  with  the  opposite  side. 

Second  Stage. — After  a  variable  time  the  thigh  becomes  adducted  and 
rotated  inward,  still  remaining  flexed.  This  is  probably  due  to  reflex 
muscular  contraction.  The  adductor  muscles  are  supplied  by  one  ol 
the  principal  nerves  (obturator)  that  supply  the  hip  joint,  but  the  in- 
version is  perhaps  less  easily  accounted  for. 

Again  in  this  position  to  conceal  the  adduction  and  to  restore  the 
parallelism  of  the  limbs  the  pelvis  is  tilted  up  on  the  affected  side  and 
the  opposite  thigh  is  abducted.  Hence  there  is  apparent  shortening 
and  measured  lengthening  (in  adduction)  on  the  sound  side.  The 
actual  length  of  the  limb  may  or  may  not  be  affected,  but  if  the  disease 
progresses  the  limb  is  shortened  by  disintegration  of  the  head  of  the 
bone,  or  by  its  dislocation  onto  the  dorsum  ilii.  This  dislocation  is 
favored  by  the  disintegration  of  the  upper  and  posterior  margin  of  the 
acetabulum,  and  the  softening  of  the  capsule. 

On  account  of  the  deep  position  of  the  hip  joint  pus  formed  in  the 
course  of  hip  disease  does  not  soon  reach  the  surface,  but,  remaining 
pent  up,  it  is  apt  to  burrow  in  various  directions  and  become  very  de- 
structive in  its  results.  The  epiphysis  that  forms  the  head  is  wholly 
v-ithin  the  joint,  and  the  conjugal  cartilage  that  unites  it  with  the  dia- 
physis,  and  ossifies  about  the  nineteenth  year,  is  usually  involved  when 
the  primary  lesion  is  in  the  bone.  This  may  cause  a  separation  of  the 
epiphysis,  or  it  may  arrest  the  growth  of  the  bone  at  this  end  and 
thus  lead  to  a  shortening  of  the  limb,  unless  compensated  by  increased 
growth  at  the  lower  end. 

The  well-known  fact  that  patients  with  hip  disease  often  complain 
of  pain  in  the  knee,  in  excess  of  or  to  the  exclusion  of  pain  in  the  hip, 
is  readily  explained  as  a  reflex.  Thus  both  hip  and  knee  joints  are 
supplied  by  filaments  from  the  obturator,  anterior  crural  and  sciatic 
nerves,  and  the  irritation  of  the  hip  joint  filaments  is  referred  to  those 
of  the  knee. 

Dislocation  of  the  Hip. — The  comparative  rarity  of  this  injury  is  due 
to  the  great  strength  of -the  joint.  In  spite  of  the  tremendous  leverage 
of  the  long  femur  it  forms  less  than  2  per  cent,  of  all  dislocations.  A 
considerable  proportion  (nearly  50  per  cent.,  Prahl)  occur  before  the 
age  of  20.  The  traumatic  dislocations  may  be  practically  divided 
into  I.  the  backward,  including  (a)  the  ischiatic  and  (b)  that  onto  the 
dorsum  ilii,  and  II.  the  forward  or  inward,  including  (a)  the  obturator 
and  ih)  the  pubic.     The  backward  dislocations  are  by  far  the  most  com- 


DORSAL    on   liA<K\VARI)   DISLOCATIOSS.  439 

mon.  The  indispensable  prerequisites  for  a  dialocation  are  rupture  of 
tiie  capsule,  of  the  liganientum  teres  and,  to  a  less  extent,  of  the  coty- 
loid ligament.  Xaturally  the  fhinncr  fxirtn  of  tlie  capsufc  arc  those  gen- 
erally torn;  the  iliofemoral  band  is  almost  never  torn,  a  fact  of  the 
utmost  importance  which  is  due  to  its  strength  and  the  fact  that  it  is 
relaxed  when  the  luxation  is  produced.  Tha  jjosition  of  the  lirnh  in 
which  dislocation  most  often  occurs  is  that  of  flexion,  adduction  and 
inward  rotation.  In  this  position  the  head  of  the  bone  proses  upon 
the  thin  postero-inferior  part  of  the  capsule,  which  tears  and  allows  the 
head  to  be  dislocated  downward  over  the  lower  and  weaker  portion  of 
the  cotyloid  rim.  The  primari/  (lispldccimnt  is  therefore  downward. 
The  secondary  displacement  is  such  as  may  be  allowed  by  the  intact 
portion  of  the  capsule,  and  especially  the  iliofemoral  band,  which  is 
now  rendered  tense.  The  attachment  of  the  latter  to  the  femur  forms  a 
new  center  of  motion,  or  the  fulcrum  of  a  lever  of  which  the  head  and 
neck  are  the  short  arm  and  the  rest  of  the  femur  the  long  arm.  If 
then  the  thigh  be  partly  lowered  (extended)  while  the  adduction  and 
inward  rotation  remain  unciianged,  the  head  glides  up  behind  the 
acetabulum  to  a  dorsal  or  l)ackward  position.  If,  on  the  other  hand, 
the  thigh  is  abducted  or  rotated  out  as  it  is  lowered,  the  head  and 
neck,  moving  on  the  new  center  of  motion,  are  forced  in  the  opjwsite 
direction  to  the  shaft  and  are  displaced  inward  and  forward.  This  is 
exemplified  in  the  reduction  of  dislocations.  When  there  is  a  back- 
ward dislocation  the  head  of  the  bone  is  brought  below  the  acetab- 
ulum by  increasing  the  flexion,  and  it  may  readily  be  converted  into 
an  inward  dislocation  by  too  much  abduction  or  outward  rotation, 
especially  if  upward  (forward)  traction  on  the  thigh  is  omitted.  In 
the  reduction  of  obturator  dislocations  Bigelow  gives  preference  to 
converting  it  into  the  dorsal  form  by  the  reverse  of  the  aix)ve 
process. 

In  dorsal  or  backward  dislocations  the  Jicdd  of  the  bone  lic.-<  be- 
hind and  above  the  acetabulum,  either  Just  behind  the  latter  and  in 
front  of  the  spine  of  the  iscliiiini,  (n)  ischiatic  •form,  or  higher  up  on 
the  ilium,  (6)  dislocation  onto  the  dorsum  ilii,  in  front  of,  and  seldom 
above,  the  apex  of  the  great  sciatic  notch.  In  the  recumbent  posi- 
tion the  latter  lies  directly  behind  the  anterior  superior  iliac  spine. 
The  head  can  be  felt  in  the  buttocks,  above  the  tuber  ischii,  beneath 
the  gluteus  maximus.  The  f/rraf  trorhantrr  is  displaced  forward  and 
approaches  nearer  the  iliac  crest  than  normally.  It  lies  from  2  to  3 
cm.,  above  Nelaton's  line  in  the  ischiatic  form,  and  from  3  to  7  cm., 
in  the  iliac  form.  The  real  i^horfeninf/  varies  within  these  limits  ;  the 
measured  shortening  is  increased  by  the  flexion  present,  but  may  be 
decreased  or  even  wholly  lacking  i)y  reason  of  the  adtluctiou  ;  the  ap- 
parent shortening  is  increased  by  the  adduction  and  flexion.  The  head 
may  pass  above  or  below  the  obturator  internus  tendon.  Although 
Bigelow  classed  all  cases  in  which  the  head  was  below  the  ten<lon  as 
ischiatic  and  all  above  as  iliac,  many  if  not  most  of  those  calhtl  iliac 
pass  below  the  tendon.     The  flexion  and  inversion  are  greater  when  the 


440  THE  LOWER  EXTREMITY. 

head  lies  below  the  obturator  tendon.  The  higher  up  the  head  rests, 
the  further  up  on  the  posterior  aspect  is  the  capsule  torn.  Usually 
the  quadratus  femoris  and  sometimes  the  obturator  internus  and  even 
the  pyriformis  tendons  are  torn.  The  /itnb  is  held  somewhat  flexed, 
adducted  and  rotated  in.  This  position  can  be  readily  exaggerated  but 
the  attempt  to  give  it  the  opposite  position  is  resisted.  The  tension  of 
the  iliofemoral  band  and  of  the  iliopsoas  muscle  and  the  position  of 
the  head  and  neck,  which  must  follow  the  plane  on  which  they  lie,  are 
largely  responsible  for  the  position  assumed  and  the  resistance  to  move- 
ment in  the  opposite  direction.  The  normal  depression  behind  the 
trochanter  is  lost  and  the  depressibility  of  the  soft  parts  below  the 
outer  half  of  Poupart's  ligament,  where  the  head  lies  normally,  is 
increased. 

In  the  inward  or  forward  dislocations  the  head  of  the  bone  passes 
forward  from  below  the  acetabulum,  along  its  inner  edge,  until  it 
reaches  the  thyroid  foramen,  («)  thyroid  form,  or,  if  the  limb  is  further 
extended  and  everted,  it  may  pass  forward  and  come  to  lie  upon  or 
near  the  iliopubic  eminence,  (6)  pubic  form.  In  both  forms  the  head 
can  be  distinguished  by  touch  or  even  by  sight  in  its  new  position, 
especially  in  the  pubic  variety.  In  the  latter  variety  the  femoral  artery 
can  be  felt  pulsating  directly  over  it,  or  to  its  inner  side.  The  great 
trochanter  is  displaced  inward  toward  the  acetabulum,  over  which  it 
may  be  felt.  The  outer  and  posterior  portions  of  the  hip  are  flattened. 
Both  the  obturator  and  anterior  crural  nerves  have  suffered  from  pres- 
sure. The  posture  of  the  limb  varies.  In  the  thyroid  variety  it  is 
flexed,  abducted  and  usually  rotated  out.  There  is  apparent  lengthen- 
ing by  reason  of  the  tilting  of  the  pelvis,  to  bring  the  abducted  limb 
into  line.  The  measurement  may  show  lengthening  on  account  of  the 
downward  position  of  the  head,  in  spite  of  the  shortening  due  to  abduc- 
tion. In  some  cases  the  head  has  passed  over  the  ramus  into  the  per- 
ineum. In  the  pubic  variety  the  limb  is  but  little  if  at  all  abducted, 
markedly  everted  and  but  little  flexed.  In  this  form  the  apparent 
lengthening  of  the  thyroid  form  may  be  wanting,  if  there  is  no  abduc- 
tion, and  there  is  measured  and  actual  s}iorte)iing.  From  its  position 
(eversion)  and  the  presence  of  shortening  it  may  be  mistaken  for  frac- 
ture of  the  neck  of  the  femur,  but  it  can  be  distinguished  from  it  by  the 
presence  of  the  l>ead  in  its  new  position,  the  depression  and  inward 
displacement  of  the  trochanter,  and  the  flattening  of  the  outer  aspect 
of  the  hip. 

In  the  reduction  of  dislocations  of  the  hip  we  may  lay  down  the 
general  ride  that  the  head  should  be  made  to  take,  in  the  reverse  direc- 
tion, the  route  it  took  in  becoming  dislocated.  The  chief  obstacle  to  re- 
duction is  the  tension  of  the  Y  ligament  in  the  partly  extended  posi- 
tion, and  to  overcome  this  the  thigh  is  first  flexed.  This  flexion  also 
brings  the  head  down  to  the  lower  part  of  the  socket,  where  it  escaped. 
As  a  general  rule  we  may  direct  to  first  (1)  increase  the  deformity  and 
then  (2)  make  the  opposite  movements.  (1)  Relaxes  the  Y  ligament, 
releases  the  head  and  brings  it  below  the  socket  while  (2)  forces  the 


FRACTURES  OF  THE  NECK  OF  THE  FEMUR.  441 

head  through  the  tear  in  the  capsule  into  the  socket.  In  the  dorsal 
form  increasing  at  first  the  adduction  and  inversion  lifts  the  head 
of  the  femur  away  from  the  pelvis  and  the  projecting  rim  of  the 
acetabulum.  At  the  same  time  unless  we  make  forward  traction  after 
flexion,  and  otherwise  increasing  the  deformity,  a  backward  dislocation 
is  likely  to  be  converted  into  a  ibrward  one  and  vice  versa.  In  other 
words  the  reduction  is  to  be  made  f"r</(li/  hij  fraction  rather  than  by 
manipulation.  The  spasmodic  contraction  of  the  muscles  op})oses  this 
forward  traction,  hence  the  value  of  anaesthesia.  Sdmson'n  method  of 
placing  the  patient  on  the  face  with  the  flexed  thigh  hanging  over  the 
end  of  the  table,  cnal)les  us  to  dispense  with  aiuesthesia  ;  for  the 
weight  of  the  limb,  tiring  out  and  overcoming  tlie  contraction  of  the 
muscles,  serves  instead  of  traction,  so  that  a  slight  rocking  of  the 
flexed  limb  accomplishes  the  reduction.  The  fonrard  or  inward  forms 
may  be  reduced  by  first  converting  them  into  the  backward  form  Ity  in- 
creasing the  deformity  and  then  making  the  opposite  movements  without 
traction,  or  they  may  be  reduced  directly  by  the  same  manipulations 
with  traction,  taking  care  not  to  carry  the  o]>posite  movements  too  far. 
It  may  be  convenient  to  remember  that  the  internal  condyle  looks 
nearly  in  the  same  direction  as  the  head  of  the  femur. 

Congenital  Dislocations  of  the  Hip. — The  hip  may  be  congenitally 
dislocated  from  lack  of  development  of  the  acetabulum,  especially  its 
upper  or  iliac  portion.  In  congenital  dislocations  the  neck  is  short 
and  the  head  is  flat  and  slips  onto  the  dorsum  of  the  ilium  when  the 
child  walks.  If  reduced  there  is  nothing  to  keep  it  from  slipping  out 
again.  When  long  displaced  the  muscles  become  shortened  so  that 
the  head  can  not  be  reduced  without  dividing  them.  A  new  socket 
may  form  on  the  ilium  from  osteophytic  outgrowths.  The  ligament nm 
teres  is  usually  stretched  and  not  torn. 

Fractures  of  the  Neck  of  the  Femur. — The  long  axis  of  the  neck 
measures  3.1  to  4  cm.,  its  vertical  diameter  averages  313  mm.,  its  antero- 
posterior 25  mm.  The  neck  forms  an  ancfle  with  the  shaft,  averaging 
125°  in  the  adult.  This  angle  is  greater  in  the  infant,  but  does  not 
decrease  after  adult  life  is  reached.  Hence  the  theory  that  the  fre- 
quency of  fractures  of  the  neck  of  the  femur  in  old  age  depends  ujion 
a  decrease  of  this  angle  to  one  nearer  a  right  angle,  a  position  that 
would  favor  fracture,  is  not  sustained  by  facts  and  has  been  abandoned. 
Nor  is  the  angle  sufficiently  less  or  the  trochanter  enough  more  promi- 
nent in  the  female  to  account  for  the  more  frequent  occurrence  of  this 
injury  in  that  sex. 

The  fact  remains,  however,  that  this  fracture  is  essential  I  ij  a  hsion  nj 
old  age,  is  more  common  in  women  than  in  men  and  is  often  the  result 
of  slight  causes,  a  stumble,  a  misstep,  or  a  slight  fall.  These  facts  in- 
dicate the  existence  of  senile  cJuinges  as  a  i)redisj)osi)ig  cause,  and  it  is 
found  that  all  parts  of  the  bone  are  much  rarefied  and  the  corticjii  sub- 
stance is  much  thinner  in  the  aged.  This  osteoporosis  afects  also  two 
plates  of  compact  bone  which  strengthen  the  neck,  (1)  the  ealcar 
femorale,  a  nearly  vertical   phite   projecting  into  the  sjH)ngy  substance, 


442  THE  LOWER  EXTREMITY. 

toward  the  great  trochanter,  from  a  little  in  front  of  the  small  tro- 
chanter, and  (2)  a  thin  dense  ji^ate,  continuous  with  the  posterior  sur- 
face of  the  neck,  which  extends  in  the  spongy  tissue  toward  the  outer 
surface  of  the  shaft  and  of  the  trochanter.  As  the  capsule  is  attached 
in  front  to  the  base  of  the  neck  (the  intertrochanteric  line)  and  behind 
half  an  inch  or  more  internal  to  the  posterior  intertrochanteric  line, 
it  follows  that  there  can  be  no  strictly  extracapsidar  fractures  of  the 
neck,  for  the  latter  is  entirely  intracapsular  in  front.  A  more  scientific 
classification  of  these  fractures  than  that  into  intracapsular  and  extra- 
capsular is  the  division  into  (a)  fractures  through  the  neck  and  (6) 
fractures  at  the  base  of  the  neck. 

(rt)  Fractures  through  the  neck  may  occur  at  any  point  be- 
tween the  junction  of  the  head  and  neck  and  the  base  of  the  latter, 
though  they  are  said  to  be  more  common  near  the  head.  It  is  this 
variety  especially  that  occurs  from  slight  violence  in  the  aged.  As 
a  rule  there  is  angular  displacement  at  the  fracture,  from  the  crushing 
of  the  bone  or  the  penetration  of  one  fragment  into  the  other  pos- 
teriorly, so  that  the  neck  is  bent  at  an  angle  directed  upward  and 
forward.  If  the  fracture  is  near  the  head  the  latter  is  penetrated  by 
the  smaller  and  more  compact  neck,  but  true  impaction  is  rare.  Tlie 
periosteum  is  usually  untorn  over  a  portion  of  the  circumference  of  the 
neck.  This  periosteum  is  reinforced  by  fibers  reflected  from  the 
femoral  attachment  of  the  capsule  toward  the  head  in  three  bands  or 
retinacula,  one  behind  and  one  at  either  end  of  the  anterior  intertro- 
chanteric line.  The  untorn  portion  of  the  periosteum  not  only  holds 
the  fragments  together,  hut  fur  7iishes  a  source  of  blood  supply  to  the 
smaller  fragment,  to  assist  in  the  process  of  repair.  The  only  other 
source  of  blood  supply  of  the  head,  after  fracture,  is  the  ligamentum 
teres. 

(6)  Fractures  at  the  base  of  the  neck  usually  follow  the  line  of 
junction  of  the  neck  and  shaft  quite  closely,  but  other  lines  of  fracture 
traverse  the  great  trochanter,  as  a  rule.  The  neck  is  as  a  rule  bent 
backward  by  the  crushing  of  its  posterior  and  more  fragile  part,  or  its 
penetration  into  the  trochanter  posteriorly.  In  this  way  the  tro- 
chanter may  be  split  into  two  or  many  pieces.  According  to  Stimson 
true  impaction,  or  fixation  with  penetration,  is  the  exception.  In  this 
form  tJie  cause  is  usually  a  fall  on  the  trochanter,  and  it  includes  most 
of  those  cases  where  fracture  occurs  before  old  age.  According  to 
Whitman  it  is  more  common  in  childhood  than  was  formerly  supposed. 
The  axis  of  the  neck  and  of  the  great  trochanter  are  not  in  the  same 
plane,  but  meet  in  an  angle,  open  posteriorly,  at  the  anterior  tro- 
chanteric line.  In  a  fall  on  the  trochanter  this  angle  is  exaggerated 
and  the  bone  gives  way  here  at  the  weakest  and  most  spongy  portion 
of  the  bone.  This  mechanism  helps  to  explain  the  greater  penetration 
behind  and  the  eversion  of  the  limb. 

The  eJisenVud  point  in  the  prognosis^  and  the  reason  for  attempting 
to  distinguish  between  these  two  forms,  lies  in  the  vitality  and  power 
■of  repair  of  the  upper  fragm.ent.      This  depends  not  so  much  upon  impac- 


SYMPTOMS  AND  SIGXS  OF  FRACTURE.  443 

tion  or  the  situation  of  the  fracture  as  upon  tiie  preservation  of  the 
blood  supply,  which  runs  toward  the  head  in  the  tliick  cervical  peri- 
osteum. These  vessels  are  not  much  injured  in  fractures  at  the  base 
of  the  neck,  and  in  those  throu<i;ii  its  narrow  part  wo  have  seen  that 
enough  of  the  periosteum  is  usually  untorn  to  preserve  the  vitality  of 
the  fragment.  The  number  of  specimens  of  undoubted  bony  union 
after  fracture  of  the  narrow  part  of  the  neck  is  sufficiently  large  not 
only  to  demonstrate  its  possibility,  but  to  indicate  that  it  is  probably 
common  enough,  with  proper  treatment,  to  justify  the  attemj)t  to 
obtain  it. 

The  symptoms  and  signs  of  fracture  of  the  neck  of  the  femur, 
upon  wJiicJi  the  diagnosis  depends,  are  (1)  interference  with  function,  (2) 
localized  pain  on  movement,  (3)  position  of  the  limb,  (4)  cre])itus, 
in  a  few  cases,  (5)  enlargement  or  widening  of  the  great  trochanter 
from  comminution,  especially  in  fractures  at  the  base  of  the  neck,  (6) 
elevation  of  the  trochanter  and  its  approach  to  the  median  line,  (7) 
swelling  and  diminished  depressibility  of  the  region  below  the  outer 
half  of  Poupart's  ligament.  In  addition  to  these  the  cause  of  the 
injury  is  important,  especially  if  it  be  trifling  and  in  an  aged  person. 
As  to  the  posture  the  injured  limb  is  everted,  slightly  flexed,  abducted 
and  it  may  appear  shortened.  T7ie  cause  of  eversion  is  largely  the 
eifect  of  gravity  in  connection  with  the  diminished  activity  of  the 
muscles  ;  it  also  depends  upon  the  angular  displacement,  with  or  with- 
out impaction.  In  addition  the  upward  displacement  relaxes  the  in- 
ternal rotator  muscles  more  than  the  external,  so  that  the  former  can 
act  only  at  great  disadvantage.  Inversion  is  sometimes  present  in- 
stead. Shortening  is  due  (1)  to  overriding  and  (2)  to  alteration  of  the 
angle  of  the  neck ;  it  v^aries  from  2  to  6  cm.  It  is  usually  greater 
in  fractures  at  the  base  of  the  neck.  In  those  through  the  narrow 
part  of  the  neck  it  may  be  slight  or  even  wanting  at  first,  and  in- 
creases gradually,  or  sometimes  suddenly,  after  a  few  hours  or  days. 
A  slight  primary  shortening  and  its  subsequent  gradual  increase  is 
thought  by  many  to  be  pathognomonic  of  fractures  through  the  neck. 
All  is  called  attention  to  the  relaxation  of  the  fascia  lata  between  the 
crest  of  the  ilium  and  the  great  trochanter  as  a  result  of  the  ele- 
vation of  the  trochanter.  Rotation  of  the  trochanter  upon  a  shorter 
radius  than  normal  is  a  theoretical  rather  than  a  practical  sign. 

An  exact  diagnosis  in  all  cases  between  "intracapsular"  and  "extra- 
capsular" fractures  is  both  impossible  and  useless.  Some  cases  of  frac- 
ture at  the  base  of  the  neck  (extracapsular)  can  be  ]iositivoly  recog- 
nized by  the  splitting  and  broadening  of  the  trochanter  and  the 
immediate  and  considerable  shortening.  Likewise  slight  violence,  ad- 
vanced age,  great  disability  and  slight  shortening  point  to  fracture 
through  the  narrow  part  of  the  neck. 

In  general  the  treatment  should  aim  t<»  secure  union,  by  means  of 
fixation  and  traction.  The  full  restoration  of  form  and  function  is  not 
often  to  be  expected.  Fairly  good  function  is  not  uncommonly  present 
after  such  injuries. 


444  THE  LOWER  EXTREMITY. 

Separation  of  the  epiphysis,  whose  conjugal  cartilage  adjoins  the 
head,  has  been  demonstrated  by  specimens  in  a  few  cases,  but  it  is  even 
rarer  than  fracture  of  the  neck  at  the  corresponding  age,  i.  e.,  before 
nineteen,  when  bony  union  occurs  (see  p.  438). 

The  great  trochanter  is  formed  as  a  separate  epiphysis,  which  in  a 
few  cases  has  been  observed  to  be  separated  from  the  shaft,  sometimes 
as  the  result  of  osteomyelitis.    Bony  union  occurs  in  the  eighteenth  year. 

Coxa  vara  is  an  affection  of  adolescence,  usually  rachitic  in  origin. 
Under  the  weight  of  the  body  the  neck  yields,  its  angle  with  the  shaft 
is  reduced  to  90°  or  less,  the  limb  is  shortened  and  the  trochanter  is 
elevated  and  made  more  prominent.  Hence  it  may  be  mistaken  for 
hip  disease  or  congenital  dislocation  of  the  hip. 

Excision  of  the  head  of  the  femur  is  sometimes  called  for  in 
hip  disease.  The  chief  anatomical  interest  in  the  operation  concerns 
the  method  of  reaching  the  'deeply  placed  joint.  An  external  incision 
(Langenbeck's  operation)  has  been  much  employed.  With  the  thigh 
flexed  at  an  angle  of  45°  and  rotated  a  little  inward  an  incision  of 
4  to  4|  inches  is  made  in  the  long  axis  of  the  limb,  so  that  one 
third  of  the  incision  is  over  the  great  trochanter,  a  little  behind  its 
center,  the  remaining  two  thirds  over  the  ilium,  reaching  up  to  the 
top  of  the  great  sciatic  notch.  In  the  position  in  which  the  limb  is 
placed  it  would  meet  the  posterior  superior  spine,  if  prolonged.  The 
gluteal  muscles  are  divided  in  a  direction  parallel  with  their  fibers, 
and  the  capsule  is  opened  in  the  same  line,  and  also  transversely  near 
the  acetabulum.  By  cutting  the  cotyloid  ligament  air  is  admitted  behind 
the  head,  thereby  equalizing  the  atmospheric  pressure  on  its  two  sides 
so  that  it  is  readily  separated  from  the  acetabulum.  This  same  pro- 
cedure is  carried  out  in  exarticulation  at  the  hip  joint,  but  in  the  lat- 
ter operation  the  ligamentum  teres  requires  division,  while  in  excisions 
it  has  usually  disappeared  as  a  result  of  the  lesion  for  which  the 
operation  is  required.  Among  the  disadvantages  of  the  external 
incision  is  the  fact  that  many  large  and  important  muscles  and  many 
of  the  arteries  that  meet  about  the  great  trochanter  are  divided.  Two 
methods  of  anterior  incision  may  be  mentioned.  In  one  (Liicke's)  the 
incision  is  made  in  the  long  axis  of  the  limb  from  a  point  half  an  inch 
below  and  internal  to  the  anterior  superior  iliac  spine,  just  external  to 
the  anterior  crural  nerve,  exposing  the  inner  border  of  the  sartorius. 
The  rectus  and  sartorius  are  retracted  externally,  the  psoas  internally, 
exposing  the  capsule  in  front.  But  it  is  difficult  to  draw  the  psoas 
aside,  the  capsule  must  be  opened  through  the  iliofemoral  ligament, 
and  the  external  circumflex  artery  can  hardly  escape  division.  Hence 
the  incision  of  Hueter,  Parker  or  Barker  \H  \ireferah\e.  This  is  carried 
downward  from  half  an  inch  below  the  anterior  superior  iliac  spine  ; 
the  tensor  vaginse  femoris  and  the  glutei  muscles  are  retracted  outward 
and  the  sartoriusand  rectus  inward,  exposing  thecapsule  more  externally. 
No  muscles  and  no  vessels  or  nerves  of  any  importance  are  divided. 

Amputation  or  exarticulation  of  the  thigh  at  the  hip  joint  is 
performed  by  various  methods.     The  control  of  hemorrhage  is  the  essen- 


THE  TIIKIH.  445 

tial  feature  of  the  operation  and  may  be  acconipfished  in  severdl  ways. 
(1)  The  femoral  artery  may  be  ligated  l)efore  the  fla])s  are  eut  or  while 
they  are  being  formed  as  in  the  "anterior  racket"  incision.  (2j  The 
femoral  may  be  compressed  in  the  Hap  by  the  fingers  of  an  assistant, 
just  before  the  vessels  are  cut.  The  fingers  are  introduced  behind  the 
vessels,  which  are  compressed  between  them  and  the  thumb  which  is  on 
thesurface.  These  methods  do  not  control  the  bleeding  from  the  branches 
of  the  internal  iliac.  Hence  (■">)  pressure  on  the  lower  end  of  the  aorta  by 
Lister's  tourniquet  has  been  used  and  also  (4)  pressure  on  the  common 
iliac  against  the  pelvic  brim  by  Davy's  lever  introduced  into  the  rec- 
tum. Both  3  and  4  have  been  generally  abandoned,  (o)  Pressure  on 
the  common  iliac  by  the  fingers  of  an  assistant  introduced  through  an 
intermuscular  incision  in  the  iliac  region  (McBurneyj,  I  have  found 
very  serviceable.  (6)  The  elastic  tourniquet  around  the  upper  end  ot 
the  limb,  with  or  without  the  use  of  long  needles,  or  skewers,  thrust 
through  the  upper  end  of  the  thigh,  to  prevent  the  rubber  tubing  or 
bandage  from  slipping  down,  is  the  method  most  generally  used.  In 
order  to  control  the  gluteal  and  sciatic  vessels  the  tourniquet  must  be 
carried  internal  to  the  tuber  ischii,  so  as  to  compress  them  as  they 
emerge  from  the  great  sacro-sciatic  foramen.  By  passing  over  the  groin 
it  compresses  the  femoral  vessels  and  by  being  carried  above  the  iliac 
crest  it  is  prevented  from  slipping  downward. 

The  varieties  of  incision  are  numerous.  We  may  make  an  "  external 
racket"  or  oval  incision,  with  the  summit  two  inches  above  the  tro- 
chanter; an  "anterior  racket"  incision,  with  the  center  at  the  middle  ot 
Poupart's  ligament ;  or  a  circular  amputation  of  the  thigh  combined 
with  an  external  vertical  incision  extending  up  two  inches  above  the 
trochanter,  etc.  The  various  incisions  have  their  own  advantages  and 
disadvantages.  The  vessels  divided  are  the  femoral,  profunda,  gluteal, 
sciatic  and  branches  of  the  external  and  internal  circumflex,  and  the 
long  saphenous  vein.  Their  position  at  the  point  of  section  varies  with 
the  form  and  length  of  the  flaps.  In  those  methods  with  long  flaps 
the  branches  of  the  gluteal  and  sciatic  arteries  are  small  and  unimpor- 
tant. In  the  "  anterior  racket  "  incision  no  tourniquet  or  compression 
is  used,  the  vessels  are  tied  as  they  are  met  with,  as  in  removing  a 
tumor,  and  very  little  blood  need  be  lost.  The  muf<cles  attached  to  the 
great  trochanter  and  the  upper  end  of  the  shaft  are  divided  close  to  the 
bone  ;  the  other  muscles,  sartorius,  rectus,  adductors,  gracilis  and  ham- 
string muscles,  are  divided  at  varying  levels. 

THE    THIGH. 

Limits. — Under  this  term  is  included  the  region  lying  below  the 
regions  last  described,  /.  c,  below  the  level  of  the  gluteal  fold,  and 
above  the  subcrural  bursa  of  the  knee,  /.  e.,  o  to  8  cm.  above  the 
patella.  It  is  more  or  less  conical  in  shape,  and  slightly  convex  in 
front  and  externally.  On  cross  section  it  is  round  in  the  female,  by 
reason  of  the  subcutaneous  fat,  triangular  in  the  male,  with  its  base 
behind.     The   thigh  is  directed  obliquely  dowuwanl  and   inward,  the 


446  THE  LOWER  EXTREMITY. 

inward  obliquity  being  more  marked  in  the  female,  on  account  of  the 
wider  separation  of  the  acetabula,  and  also  in  short  subjects. 

Surface  Markings  and  Landmarks. — The  rectus  muscle  forms  a 
prominence  in  front,  most  noticeable  when  the  muscle  is  in  action. 
On  either  side  of  this  prominence,  and  most  conspicuous  in  the  lower 
half  of  the  thigh,  is  a  slight  eminence  formed  by  the  vasti  muscles,  the 
inner  one  being  the  more  marked.  Along  the  inner  aspect  of  the 
thigh,  from  the  apex  of  Scarpa's  triangle,  is  a  ^/'oore  indicating  the  in- 
terval between  the  adductors  and  the  quadriceps  femoris.  In  this  groove 
lie  the  femoral  vessels  and,  more  superficially,  the  sartorius  muscle. 
The  outer  surface  of  the  thigh  is  jfiattened  or  slightly  depressed  by  the 
iliotibial  band  of  the  fascia  lata.  At  the  junction  of  the  external  and 
posterior  aspects  of  the  thigh  the  position  of  the  external  intermuscular 
septum,  corresponding  to  the  interval  between  the  hamstring  muscles 
and  the  vastus  externus,  is  indicated  by  a  slight  depression,  and  is  per- 
ceptible to  palpation.     The  bone  can  not  be  plainly  palpated. 

Topography. — The  line  of  the  femoral  vessels  (see  p.  431)  and  the 
sciatic  nerve  (see  p.  427)  have  already  been  given.  The  sciatic  nerve 
usually  bifurcates  near  the  middle  of  the  thigh  and  its  internal  popliteal 
branch  continues  the  direction  of  the  trunk.  The  long  saphenous  vein 
follows  the  course  of  the  inner  border  of  the  sartorius  muscle  in  a  line 
from  the  saphenous  opening  (see  p.  431)  to  the  posterior  border  of  the 
muscle  at  the  level  of  the  internal  condyle.  It  is  not  infrequently 
double  in  the  thigh.  The  long  saphenous  nerve  follows  the  femoral 
artery,  crossing  to  its  inner  side  in  front  of  the  artery  in  Hunter's 
canal.  Emerging  through  the  anterior  wall  of  this  canal  it  passes 
under  cover  of  the  sartorius  in  the  lower  fourth  of  the  thigh  and  lies 
to  the  inner  side  of  the  knee. 

The  skin  of  the  thigh  is  coarse  on  the  outer  side,  thin  and  fine  in- 
ternally, and  is  often  used  in  .s7;//i  grafting.  Its  loose  attachment  to  the 
deep  fascia  favors  the  performance  of  circular  amputations,  as  no  dis- 
section of  a  skin  flap  is  required,  merely  the  upward  retraction  by  an 
assistant.  Along  the  line  of  the  external  intermuscular  septum  it  is 
a  little  more  adherent  and  may  require  freeing  with  the  knife.  The 
laxity  of  tJie  subcutaneous  tissue,  which  contains  a  very  variable  quantity 
of  fat,  allows  the  stripping  up  of  large  flaps  of  skin  or  the  formation 
of  extensive  extravasations  beneath  it,  in  case  of  injury.  According 
to  Tillaux,  the  long  saphenous  vein  is  contained  in  a  sheath  derived 
from  the  fascia  lata  in  the  middle  third  of  the  thigh,  elsewhere  it  is 
subcutaneous. 

The  fascia  lata  resists  the  extension  of  tumors,  abscesses  and  deep 
extravasations  of  blood,  especially  on  the  outer  aspect  where  it  is 
stronger.  Through  rents  or  cuts  in  the  fascia  lata  the  underlying  mus- 
cle has  occasionally  bulged  and  been  caught  forming  a  so  called  hernia 
of  the  muscle.  The  quadriceps  and  adductor  longus  have  been  thus 
herniated.  From  the  deep  surface  of  the  fascia  two  fibrous  septa  pass 
inward  to  the  two  lips  of  the  linea  aspera  and  divide  the  thigh  into  an 
anterior  and  a  posterior  compartment.     This  division  has  little  surgical 


PLATE   LI  1 

FIG.  lOo. 


VASTUS    EXT. 
MUSCLE 


FASCIA     LATA 


RECTUS-FEMO- 

"~RIS    MUSCLE 

VASTUS     INT. 

MUSCLE 

,,SARTOniUS    M. 
^FEMORAL    ART. 
INT.    SAPHE- 
NOUS   VEIN 
I  NT.    SAPHE- 
^    NOUS    NERVE 
a  DDUCTOR 
LONGUS    M. 
rOEEP   FEMO- 
^     RAL    ART. 

ADDUCTOR 


EXT.    INTERMUS- 
CULAR   SEPTUM 


CMITENDI- 
NOSUS    MU5. 


GREAT    SCIATIC  POST.    INTERMUS- 

NERVE  CULAH    SEPTUM 


Cross    section    of  the    middle    of   the    right   thigh. 
Upper  segment  of  the  section.     (Tillaux.) 


FRACTURES  OF  THE  FEMUR.  447 

importance.  The  internal  intermuscular  septum  separates  the  vastus 
internus  from  the  adductors,  and  is  very  thin  and  unimportant.  7'he 
externdl  separates  tiie  vastus  externus  from  the  ham?-tring  musch-s.  Ac- 
cording to  Tilhuix  another  septum,  passing  outward  from  the  fascia 
lata  at  the  junction  of  the  inner  and  posterior  aspects  to  the  exter- 
nal intermuscular  septum,  separates  the  adductor  from  the  hamstring 
group  of  muscles. 

The  femoral  artery  may  be  ligated  at  any  part  of  its  course, 
which  has  already  been  given  (see  p.  431).  The  "place  of  election" 
is  at  the  apex  of  Scarpa's  triangle.  It  may  al.so  be  ligated  at  the  i>a.se 
of  the  triangle  (common  femoral)  or  in  Hunter's  canal.  The  latter 
lies  at  the  lower  end  of  the  middle  third  »jf  the  thigh,  beneath  the  sar- 
torius  muscle,  which  is  retracted  internally  to  reach  it.  It  nuasarcs 
five  to  six  cm.  in  length,  and  is  bounded  by  the  adductor  longus  be- 
hind, the  vastus  internus  externally,  and  in  front  by  a  firm  mem- 
branous layer  of  oblique  tendinous  fibers  passing  from  the  adductor 
magnus  downward  and  outward  to  the  vastus  internus.  The  vein  here 
lien  behind  and  somewhat  external  to  the  artery,  quite  closely  con- 
nected with  it,  and  an  extra  vena  comes  may  lie  in  front  of  the  artery 
and  complicate  its  ligation.  The  lo)i(j  saphenou.s  nerve  lies  in  the  canal, 
in  front  and  slightly  external  to  the  sheath  of  the  vessels.  Within  the 
canal  it  crosses  in  front  of  the  vessels,  which  it  accompanies  to  the 
opening  in  the  adductor  magnus,  where  it  perforates  the  canal  and 
passes  beneath  the  sartcrius.  The  vastus  internus  separates  the  artery 
from  the  femur  on  the  outer  side  of  the  vessel,  so  that  in  coinpre.^sion 
of  the  artery,  which  must  be  made  from  within  outward,  there  is  no 
firm  bed  against  which  to  compress  it.  In  rare  instances  the  femoral 
artery  is  replaced  by  two  trunks.  It  is  occasionally  ligated  for  popli- 
teal aneurism  or  for  wounds. 

The  great  sciatic  nerve  usually  di rides  into  the  internal  and  ex- 
ternal popliteal  nerves  about  the  middle  of  the  thigh,  not  infrequcntlv 
higher  up,  even  within  the  pelvis,  and  occasionally  lower  down.  Below 
the  lower  border  of  the  gluteus  maximus  it  is  quite  superficial  and  a 
little  lower  is  crossed  by  the  biceps,  ^it  the  middle  of  the  fhi(/h  if  lies 
between  the  biceps  behind  and  the  adductor  magnus  in  front,  beneath 
or  anterior  to  the  thin  fascial  layer  separating  the  hamstring  and  ad- 
ductor muscles.  Lower  down  it  lies  between  the  hamstring  muscles 
which  are  internal  and  external  to  it.  It  is  mrronnded  hii  a  lavcr  of 
loose  connective  tissue  and  fat,  continued  downward  from  the  pelvis. 
This  tissue  affords  a  favorable  pathway  for  the  sinking  of  abscesses, 
even  from  the  pelvis  to  the  lower  thigh  or  the  popliteal  space. 

The  place  of  election  for  opening  deep  abscesses  of  the  thigh  or  the 
removal  of  sequestra  from  the  femur  is  the  external  surface,  for  here 
the  bone  is  not  very  deep  and  there  are  no  important  vessels  or 
nerves. 

Fractures  of  the  Femur. — The  shaft  of  the  femur  may  be  frac- 
tured at  any  part,  but  mo^t  eoviinonli/  at  the  midiUe  third,  which  is 
affected  by  the  leverage  of  both  ends.     The  fracture  is  uaually  obli(jue, 


448  THE  LOWER  EXTREMITY. 

but  may  be  transverse,  especially  in  children  and  in  direct  fractures, 
which  are  most  common  in  the  lower  half.  Fractures  in  the  upper 
half  are  almost  always  oblique.  The  obliquity  usually  corresponds 
to  the  normal  curvature  of  the  bone.  Thus  it  cominonly  runs:  from 
behind  forward  and  downward  in  the  middle  third,  forward  and  out- 
ward in  the  upper  third.  The  displacement  is  marked  and  is  the  re- 
sult of  the  fracturing  violence,  the  contraction  of  the  thigh  muscles  and 
the  swelling  beneath  the  firm  fascia  lata,  by  means  of  which  the  thigh 
is  necessarily  shortened  at  the  same  time  that  it  is  swollen.  In  addi- 
tion there  is  an  angular  displacement,  usually  directed  forward,  or  for- 
ward and  outward,  in  the  direction  of  the  natural  curve  and  attributed 
to  the  contraction  of  the  adductor  muscles,  which  form  the  arc  of  the 
curve.  The  lower  fragment  may  also  be  rotated  out  by  gravity.  In 
fractures  of  the  upper  third  the  usual  forw^ard  and  outward  displacement 
of  the  lower  end  of  the  upper  fragment  is  largely  due  to  muscular  action. 
(1)  The  adductors  and  hamstring  muscles  draw  the  lower  fragment 
up  and  in,  behind  the  upper  fragment,  and  tilt  the  latter  forward  and 
outward.  (2)  The  psoas  and  gluteal  muscles  also  tilt  the  upper  frag- 
ment forward  and  outward.  The  sharp  ends  of  an  oblique  fracture  may 
be  driven  into  and  caught  in  the  surrounding  muscles,  which,  being 
interposed  between  the  fragments,  prevent  reduction  of  the  deformity 
and  lead  to  delayed  union  or  non-union.  The  artery  or  vein  are  rarely 
torn  or  compressed  by  the  fragments,  an  injury  leading  to  gangrene.  I 
have  seen  one  such  case.  In  fractures  in  the  lower  third  the  lower 
fragment  may  be  tilted  backward,  probably  by  the  action  of  the 
gastrocnemii. 

Except  in  rare  cases  of  transverse  or  incomplete  fractures,  the  limb 
is  always  shortened.  This  shortening  may  vary  from  a  fraction  of  an 
inch  to  four  or  even  six  inches,  and  is  due  to  the  overriding  and  the 
angular  displacement  of  the  fragments.  A  principal  object  of  treatment  is 
the  overcoming  of  this  shortening  by  continued  extenmon.  Practically  union 
never  occurs  w'ithout  shortening,  though  the  possibility  of  union  without 
shortening  may  be  admitted.  The  average  amount  of  shortening  after 
union  is  f  inch,  though  1|  inches  of  shortening  may  occur  without  a 
limp  in  the  gait,  the  shortening  being  compensated  by  the  tilting  of 
the  pelvis.  In  this  connection  it  may  be  noted  that  the  lower  limbs 
are  usually  of  unequal  length,  the  inequality  averaging  \  inch,  the 
left  being  the  longer  as  a  rule  (Wight).  In  only  about  10  per  cent, 
of  cases  are  they  of  equal  length,  so  that  using  one  limb  as  a  standard 
of  length  for  the  other  is  inaccurate.  In  the  treatment  of  fractures 
of  the  upper  third  the  entire  limb  should  be  flexed  and  abducted  to 
coincide  with  the  forward  and  outward  tilting  of  the  upper  frag- 
ment. 

In  amputation  at  or  below  the  middle  of  the  thigh  the  circular 
method  is  easy  and  gives  good  results.  The  ease  of  retraction  of  the 
skin  flap  has  l)een  referred  to,  and  the  thigh  is  seldom  so  conical  as 
to  require  the  sjilitting  of  this  flap.  The  muscles  retract  unevenly,  those 
attached  to  the  femur  retracting  but  little,  those  not  so  attached,  the 


LANDMARKS  ABOUT  THE  KWEE.  449 

free  muscles  (sartorius,  rectus,  gracilis  and  hamstriug),  retracting  con- 
siderably. Hence  the  stump  is  retracted  and  the  muscles  are  divided 
a  second  or  even  a  third  time. 

THE   REGION   OF   THE   KNEE. 

Limits. — This  includes  the  region  l)et\veen  the  k'V<'l  oi  the  upper 
end  of  the  subcrural  bursa,  8-4  fingers'  breadth  or  5-H  cm.  above  the 
patella,  and  the  level  of  the  tubercle  of  the  tibia. 

Landmarks  and  Surface  Markings. — (1)  Antero-lateral  Region. 
— The  patella  is  plainly  seen  and  felt  in  front,  its  inner  l)order  being 
somewhat  the  more  prominent.  In  the  extended  position  of  the  limb 
the  patella  can  be  moved  to  and  fro,  when  the  quadriceps  is  relaxed,  but 
is  drawn  np  and  firmly  fixed  against  the  femur  when  the  muscle  is  con- 
tracted. When  the  knee  is  flexed  the  patella  occupies  the  hollow  i)e- 
tween  the  two  bones,  and  is  not  so  readily  palpated.  In  this  position 
we  can  feel,  above  the  patella  and  through  the  quadriceps  exj)ansion, 
the  trochlear  surface  of  the  /ewuo',  especially  its  prominent  outer  border. 
A  line  from  the  upper  angle  of  this  border  to  the  adductor  tubercle 
marks  the  level  of  the  epiphysial  line.  The  adductor  tubercle  is  felt  at 
the  upper  end  of  the  internal  condyle.  It  is  just  above  the  epiphyseal 
line  and  is  the  favorite  situation  for  exostoses  in  adolescence.  The 
internal  condyle  and  its  tuberosity  are  more  prominent  than  the  outer, 
but  the  outer  tuberosity  of  the  tibia  is  more  prominent  than  the  inner. 
The  tubercle  of  the  tibia  is  plainly  felt  at  the  upper  end  of  the  anterior 
tibial  border,  and  at  the  lower  end  of  the  ligamentum  patellje.  About 
on  a  level  with  the  tubercle,  the  head  of  the  fibula  is  felt  on  the  postero- 
external aspect,  1  cm.  below  the  joint  line. 

In  the  semiflexed  position  of  the  knee,  when  the  quadriceps  muscle 
is  contracted,  the  ligamentum  patellae  can  be  plainly  felt,  and  often 
seen,  as  a  ridge  extending  from  the  apex  or  lower  end  of  the  patella  to 
the  tubercle  of  the  tibia.  In  this  position  there  is  a  slir/ht  groove  on 
either  side  of  the  tendon  but  in  the  extended  position,  when  the 
quadriceps  is  relaxed,  the  grooves  are  not  marked.  In  stout  subjects 
the  grooves  may  be  obliterated  by  fat,  which  is  found  most  abun- 
dantly behind  the  upper  half  of  the  tendon,  separating  it  from  the 
synovial  cavity.  The  ligamentum  patelhie  lies  in  the  axis  of  the  leg 
and  hence  forms  a  slight  angle  with  the  direction  of  the  quadriceps. 
On  either  side  of  the  patella  is  a  slight  groove,  which  is  obliterated  by 
effusion  into  the  joint  and  may  be  filled  with  fat  in  the  obese.  In 
stout  subjects  the  patella  may  appear  to  lie  in  the  bottom  of  a  groove 
instead  of  on  a  ridge.  Above  the  jndella  is  a  dejiression  which  is  con- 
verted into  a  prominence  in  case  of  effusion  into  the  joint.  On  both 
sides,  but  particularly  on  the  inner  side,  the  interarticular  line  between 
the  tibia  and  femur  can  be  felt  as  a  slight  de])ression  in  normal  condi- 
tions. This  is  just  aliove  the  level  of  the  apex  of  tiie  patella,  which 
serves  as  a  convenient  landmark  to  it.  It  is  here  tliat  one  feels  for  a 
displaced  semilunar  cartilage.  The  iliotibial  band  of  the  fascia  lata, 
descending  between  the  patella  and  the  back  of  the  external  condyle  to 
29 


450  THE  LOWER  EXTREMITY. 

the  external  tuberosity  of  the  tibia,  may  be  felt  as  a  rounded  band, 
most  distinctly  when  the  joint  is  forcibly  extended. 

Posterior  or  Popliteal  Region. — In  this  region  the  landmarks  are  best 
felt  when  the  knee  is  slightly  flexed.  In  this  position  the  concavity  of 
the  space  appears,  while  in  the  extended  position  it  is  flat  or  bulging. 
At  the  outer  side,  behind  the  iliotibial  band,  the  tendon  of  the  biceps  is 
felt  descending  to  the  head  of  the  fibula.  Directly  in  front  of  it  the 
upper  part  of  the  external  lateral  ligament  is  palpable,  and  close  to  its 
inner  border  the  external  popliteal  nerve  is  readily  felt  as  a  rounded 
cord.  In  its  descent  the  nerve  crosses  the  neck  of  the  fibula,  where  it 
may  be  rolled  under  the  finger  before  it  enters  the  peroneus  longus. 
The  internal  popliteal  nerve  may  be  felt  and,  in  thin  subjects,  even  seen 
descending  vertically  in  the  middle  of  the  space.  On  the  inner  side 
from  without  inward  we  can  feel  the  long  and  slender  tendon  of  the 
semitendinosus,  the  thicker  and  less  prominent  tendon  of  the  semimem- 
branosus, and  the  gracilis.  The  last  two  appear  as  one  tendon  but  by 
a  little  manipulation  we  can  insinuate  the  finger  between  them.  The 
popliteal  lymph  nodes  when  normal  can  not  be  felt.  At  the  lower  end 
of  the  space  we  can  feel  the  converging  fleshy  heads  of  the  gastrocne- 
mius. In  the  flexed  position  a  crease  in  the  skin  crosses  this  space  some 
distance  above  the  joint  line.     It  disappears  in  extension. 

Topography. — The  popliteal  artery  enters  the  popliteal  space  be- 
neath the  semimembranosus,  a  little  to  the  inner  side  of  the  middle 
line,  and  thence  runs  in  a  line  to  the  interval  between  the  two  heads 
of  the  gastrocnemius  at  the  center  of  the  lower  end  of  the  space.  It 
descends  at  first  obliquely  outward,  reaches  the  middle  line  opposite  the 
joint,  and  thence  runs  vertically.  It  bifurcates  on  a  level  with  the 
tubercle  of  the  tibia.  It  lies  against  the  back  of  the  femur,  the  pos- 
terior ligament  of  the  knee  and  the  popliteus  muscle  and  can  be  com- 
pressed against  the  femur  in  the  upper  part  of  the  space,  where  also  its 
pidsations  can  be  felt.  The  popliteal  vein  lies  behind  it,  to  its  outer 
side  above,  but  it  crosses  to  its  inner  side  below.  The  internal  popli- 
teal nerve  descends  in  the  middle  line,  continuing  the  course  of  the 
great  sciatic,  and  is  superficial  to  the  vein,  by  which  it  is  separated 
from  the  artery. 

The  superior  articular  arteries  run  transversely  just  above  the  con- 
dyles of  the  femur ;  the  inferior  articular  arteries  are  just  above  the 
head  of  the  fibula  externally,  and  a  little  below  the  internal  tuberosity 
of  the  tibia  internally.  The  deep  branch  of  the  anastomotica  magna 
descends  in  front  of  the  adductor  magnus  to  the  internal  condyle,  the 
superficial  part  runs  with  the  internal  saphenous  nerve.  The  sliort 
saphenous  i-cin  perforates  the  deep  fascia  at  the  lower  part  of  the  popli- 
teal space  in  the  middle  line.  It  is  not  visible  as  a  rule  unless  vari- 
cose and  it  has  been  suggested  (Herapat)  that  varices  of  this  vein  may 
depend  upon  a  narrowness  of  the  opening  in  the  fascia.  The  long 
saphenous  vein  passes  along  the  back  of  the  internal  condyle,  above 
which  it  lies  along  the  posterior  border  of  the  sartorius.  It  is  joined 
by  the  internal  saphenous  nerve  just  below  the  joint  line. 


THE  SOFT  PARTS  BEHIND   THE  KNEE.  451 

Soft  Parts  in  Front  of  the  Knee. — The  skin  is  thick  and  very 
movable,  thus  permitting  incisions  into  the  joint  to  be  very  indirect  or 
valvular  when  desired.  The  deep  fascia,  continuous  with  the  fascia  lata, 
is  attached  to  the  two  tuberosities  and  the  tubercle  of  the  tibia  and 
strengthens  the  joint  on  either  side  of  the  patella.  This  part  of  the 
joint  is  also  strengthened  by  the  lateral  expaihsiou.s  of  tlir  quadriceps 
tendon,  which  are  connected  with  the  sides  of  the  patella  and  liganien- 
tum  patellae  anteriorly  and  reach  as  far  as  the  lateral  ligaments  pos- 
teriorly. Hence  they  are  called  lateral  patellar  ligarnentj^.  In  frac- 
tures of  the  patella,  where  there  is  any  considerable  separation  of  the 
fragments,  there  is  always  more  or  less  of  a  tear  in  the  lateral  ex))an- 
sion  on  either  side  of  the  line  of  fracture. 

There  are  two  bursae  in  this  region  that  require  mention.  (1)  The 
prepatellar  bursa  lies  in  front  of  the  lower  two  thirds  of  the  patella 
and  the  upper  end  of  the  ligamentum  patellae.  It  does  not  reach  the 
internal  border  but  often  projects  over  the  external  border  of  the 
patella.  Although  it  is  often  described  as  separating  the  patella 
from  the  skin,  it  lies,  according  to  Tillaux,  beneath  the  deep  fascia. 
Others  (Gruber,  Joessel,  etc.)  describe  bursae  in  three  situations, 
beneath  (1)  the  skin,  (2)  the  superficial  fascia  and  (3)  the  deep  fascia, 
of  which  the  last  is  the  most  constant.  When  more  than  one  is 
enlarged  they  are  separated  wholly  or  partly  by  septa  which  easily 
yield  to  inflammatory  changes,  so  that  in  opening  a  purulent  pre- 
patellar bursitis  a  single  cavity  is  often  found.  The  bursa  is  ofteii 
enlarged  and  not  infrequently  inflamed  in  those  who  kneel  much,  such 
as  housemaids,  etc.,  hence  prepatellar  bursitis  is  commonly  known  as 
"  house-maids'  hieeJ"  Suppurative  bursitis  may  lead  to  caries  of  the 
patella,  from  which  the  bursa  is  separated  only  by  the  periosteum.  I 
have  also  met  with  tubercular  inflammation  of  this  bursa.  (2)  The 
small  bursa  between  the  patellar  ligament  and  the  tubercle  of  the  tibia  is 
separated  from  the  synovial  cavity  by  a  pad  of  fat  lying  behind  the 
upper  end  of  the  ligament.  It  does  not  communicate  with  the  joint 
and  is  not  often  enlarged  or  inflamed.  An  indistinct  feeling  of  fluc- 
tuation on  either  side  of  the  upper  end  of  the  patellar  ligament  is  often 
due  to  the  loose  fat  beneath  it  and  not  to  an  enlargement  of  this  bursa. 
This  fat  often  protrudes  a  little  on  either  side  of  it,  and  thus  still 
further  simulates  an  enlarged  bursa. 

The  soft  parts  at  the  back  of  the  knee  either  bound  or  are  con- 
tained in  the  popliteal  space.  The  skin  covering  it  is  not  so  movable 
as  in  front,  and  the  contraction  of  a  cicatrix  resulting  from  burns, 
ulcerations  or  injury  may  result  in  a  bent  knee.  In  straightening  a 
knee,  long  anehylosed  in  the  flexed  position,  the  skin  at  the  Imrk  is 
liable  to  be  torn.  The  deep  fascia,  continuous  with  the  fascia  lata 
above,  has  no  bony  attachments  here.  Its  flrmness  limits  the  exten- 
sion toward  the  surface  of  ])opliteal  tumors  or  abscesses.  Hence  being 
pent  up  in  the  popliteal  si)ace  they  cause  severe  pain  and  tend  to 
spread  down  into  the  leg  on  up  into  the  thigh.  From  the  latter  region 
abscess  may  extend  to  the  popliteal  space  through  the  opening  in  the 


452  THE  LOWER  EXTREMITY. 

adductor  magnus  for  the  femoral  vessels,  or  they  may  follow  the  great 
sciatic  nerve  from  the  thigh,  the  buttocks  or  the  pelvis. 

The  muscles  which  bound  the  space,  and  give  it  a  lozenge  shape,  are 
the  biceps  above  and  externally,  the  semitendinosus  and  semimem- 
branosus above  and  internally,  and  the  two  heads  of  the  gastrocnemius 
below  and  on  either  side.  The  upper  muscles,  known  as  the  hamstring 
muscles,  are  the  cause  of  flexion  of  the  knee  in  knee  joint  disease,  from 
the  irritation  of  articular  filaments  of  the  sciatic  nerve,  motor  branches 
of  which  supply  these  muscles.  Continued  flexion  in  this  disease  leads 
to  a  partial  backward  luxation  of  the  tibia  and  to  the  contracture  and 
shortening  of  these  muscles.  According  to  Tillaux,  the  biceps  and  semi- 
tendinosus are  frequently  shortened  in  these  conditions,  the  semimem- 
branosus rarely  so.  The  shortened  tendons  require  tenotomy  prior  to 
straightening  the  knee.  In  tenotomy  of  the  biceps  the  relation  of  the 
external  popliteal  nerve  just  internal  to  it  is  to  be  borne  in  mind. 
Contraction  or  contracture  of  the  muscle  renders  the  tendon  more 
superficial  and  increases  its  distance  from  the  nerve.  To  diminish  the 
risk  of  cutting  the  nerve  the  tendon  should  be  cut  from  within  outward 
about  3  cm.  above  the  head  of  the  fibula.  The  hamstring  tendons, 
especially  the  biceps,  may  be  ruptured  by  violence  in  the  position  of 
extreme  flexion  of  the  hip  while  the  knee  remains  extended,  a  position 
in  which  they  are  greatly  stretched. 

The  popliteal  vessels  lie  deeply  and  are  well  protected,  hence  they 
are  seldom  wounded.  The  artery  however  is  more  often  the  seat  of 
aneurism  than  any  other,  with  the  exception  of  the  thoracic  aorta. 
Many  factors  have  been  adduced  to  account  for  this  disposition.  (1)  It 
divides  into  two  large  vessels.  (2)  It  is  supported  by  the  lax  tissue 
of  the  popliteal  space,  and  not  by  muscles.  (3)  Its  course  is  curved, 
in  the  flexed  position,  like  the  thoracic  aorta.  (4)  It  is  subjected  to 
frequent  and  extensive  movement.  In  straightening  the  bent  knee  in 
cases  of  chronic  knee  joint  disease  the  artery  may  be  ruptured.  In  this 
respect  cuneiform  resection  of  the  knee  is  a  safer  operation  than  forcible 
straightening.  Forced  flexion  of  the  knee  aflects  the  lumen  of  the 
artery  as  shown  by  the  diminished  pulse  at  the  dorsalis  pedis  artery. 
When  the  artery  is  the  seat  of  an  aneurism,  the  pressure  exerted  by 
forced  flexion  of  the  knee  stops  the  circulation,  and  popliteal  aneurisms 
have  been  successfully  treated  in  this  way.  The  relations  of  the  artery 
to  the  vein  and  the  internal  popliteal  nerve  explain  the  oedema  of  the 
leg  and  the  nerve  symptoms  due  to  the  pressure  of  an  aneurism  on  these 
structures.  The  close  relations  of  the  artery  to  the  posterior  ligament, 
on  which  it  lies,  explains  the  occasional  penetration  of  an  aneurism 
into  the  joint.  The  artery  is  more  closely  connected  with  the  posterior 
ligament  below  than  above  the  joint  line,  hence  Tillaux  recommends 
sawing  the  tibia  from  behind  forward  in  resection  of  the  knee  to  avoid 
accidental  wound  of  the  artery,  but  this  is  not  necessary  with  ordinary 
care.  A  backward  luxation  of  the  tibia  has  occasionally  been  compli- 
cated by  rupture  of  the  artery.  Anomalies  of  the  artery  are  rare  and 
consist  mainly  in  a  high  division. 


PLATE   LI  I  I 


FIG.  106. 


:mimembbanosus    \ 

MUSCLE  "^ 


TIB.    COMMUNIC. 
NERVC 
EXTERNAL 
SAPHENOUS 

VEIN 


EXTERNAL    POPLIT- 
EAL   NERVE 
NTERNAL    POPLIT- 
EAL   NERVE 
°OPLITEAL    ARTERY 
POPLITEAL    VEIN 


CRON.     COMMUNiC 
NERVE 


Lperon.    LONGUS 
MUSCLE 


Popliteal   region  of  the  right  side.     (Joessel.l 


THE  KNEE  JOINT.  453 

The  popliteal  vein  is  so  doHcly  wllurent  to  (Iw  artery  tliat  some  diffi- 
culty may  be  found  in  separating  the  two  in  ligature  of  the  latter.  In 
spite  of  its  more  superficial  position  than  the  artery,  the  vein  is  rup- 
tured by  violence  even  less  often  than  the  artery  and,  according  to 
Treves,  never  alone.  This  may  be  owing  to  the  circumstance,  noted  by 
Tillaux,  that  it  is  so  thick  that  it  does  not  collapse  on  section,  and  thus 
resembles  an  artery  so  closely  that  it  may  readily  be  mistaken  for  it 
in  operations  on  the  cadaver. 

The  lymph  nodes  of  the  ix)pliteal  space  consist  of  only  four  small 
nodes,  one  just  beneath  the  fascia  and  below  the  opening  for  the  short 
saphenous  vein,  the  others  along  the  artery.  They  are  rarely  swollen 
and,  when  involved,  form  a  median  tumor,  unlike  those  derived  from 
the  l)ursje. 

The  bursae  at  the  back  of  the  knee  are  situated  on  either  aide,  two 
on  the  inner  and  four  on  the  outer  side.  Many  of  these  are  not  con- 
stant and  are  unimportant  on  account  of  the  fact  that  they  never  com- 
municate with  the  joint  and  are  seldom  enlarged. 

1.  Between  the  internal  condyle  and  the  inner  head  of  the  gastroc- 
nemius and  extending  between  the  latter  and  the  semimembranosus 
is  the  largest  bursa  of  this  region  and  the  one  most  often  inflamed. 
It  communicates  with  the  joint  in  fully  fifty  per  cent,  of  cases  (Gruber) 
and  more  often  in  adults  and  in  robust  subjects.  Its  slit-like  opening 
into  the  joint  may  become  closed  by  the  tightening  of  the  posterior 
ligament  in  extension,  which  may  explain  its  firm  feeling  in  extension, 
in  contrast  with  its  more  flabby  feeling  in  flexion.  In  the  latter  posi- 
tion it  may  sometimes  entirely  disappear  on  pressure.  It  may  become 
enlarged  in  effusions  into  the  joint,  or  independently.  (2)  A  small 
inconstant  bursa,  between  the  semimembranosus  and  the  tuberosity  of 
the  tibia,  may  communicate  with  (1)  but  never  directly  with  the  joint. 
O71  the  Older  side  there  is  (3)  a  bursa  between  the  popliteus  tendon  and 
the  external  lateral  ligament,  without  joint  connection,  and  (4)  one  be- 
tween the  same  tendon  and  the  external  tibial  tuberosity.  The  latter 
bursa  is  strictly  a  diverticulum  from  the  joint  and,  by  occasionally  com- 
municating/ with  the  upper  tibiofibular  joi)d  (in  about  fourteen  per  cent, 
of  cases,  Gruber),  connects  the  latter  with  the  knee  joint.  (5)  A  bursa 
between  the  outer  head  of  the  gastrocnemius  and  the  external  condvle 
is  neither  constant  nor  connected  with  the  joint.  (6)  One  between  the 
biceps  and  the  external  lateral  ligament  is  more  constant  but  is  also  not 
connected  with  the  joint.  Tumors  due  to  a  bursitis  are  situated  lafrrally 
and  Hsuallij  intcrndl/f/,  but  median  cysts  may  occur  in  the  popliteal  space 
due  to  the  hernial  protrusion  of  the  synovial  membrane  through  small 
openings  in  the  posterior  ligament. 

The  knee  joint  oircs  its  strmf/fh  to  that  of  the  ligaments,  tendons 
and  fasciie,  which  join  together  and  surround  its  component  parts. 
By  reason  of  its  strength  and  the  large  extent  of  its  opposing  surfaces, 
traumatic  dislocation  is  uncotnmon  in  spite  of  its  exposure  to  injury, 
and  only  occurs  from  severe  violence.  The  most  common  form  is  dis- 
location of  the  tibia  forward  by  direct  violence  or  by  hyperextension, 


454  THE  LOWER  EXTREMITY. 

the  next  commonest  is  dislocation  of  the  tibia  backward.  The  lesion 
is  a  grave  one  because  of  the  great  violence  required  and  the  frequency 
of  compounding  and  of  injury  of  the  popliteal  vessels. 

When  the  femur  is  held  vertically  the  plane  of  the  lower  surfaces  of 
the  two  condyles  is  not  horizontal,  as  is  that  of  the  upper  surfaces  of  the 
tibia,  but  the  inner  condyle  projects  lower  than  the  outer.  Hence  to  make 
the  joint  surfaces  parallel  the  femur  must  be  inclined  inward,  the  position 
it  normally  occupies  in  the  body.  Another  result  of  this  inclination  is  to 
bring  the  knees  together,  although  the  hips  are  widely  separated,  and, 
as  the  tibia  descends  nearly  vertically,  the  ankles  are  also  in  contact. 

In  the  condition  known  as  knock  knee  or  genu  valgum  the  knee  is  un- 
usually prominent  internally.  This  condition  is  due  to  an  overgrowth  of 
the  internal  condyle,  unevenness  of  the  tibial  facets,  curvature  of  the 
bones,  or  relaxation  of  the  internal  ligaments  of  the  joint,  with  or  without 
contraction  of  the  tissues  on  the  outer  aspect.  Overgrovih  of  the  internal 
condyle  is  the  common  cause,  and  may  occur  primarily  or  as  the  result 
of  relaxation  of  the  ligaments  on  the  inner  side.  By  this  relaxation 
the  pressure  between  the  bones  on  the  inner  side  is  diminished,  but  the 
actual  separation  of  the  bony  surfaces,  thus  rendered  possible,  is  pre- 
.vented  by  the  downward  growth  of  the  inner  condyle.  The  pressure 
between  the  bones  on  the  outer  side  is  increased,  whereby  the  latter 
undergo  some  atrophy  and  the  deformity  is  thus  increased.  Knock 
knee  is  commonly  due  to  rickets  and  occurs  most  often  between  the  ages 
of  two  and  four.  When  it  occurs  in  adolescents  it  is  not  commonly 
due  to  rickets  but  to  a  relaxation  of  the  ligaments  and  muscles.  Ac- 
cording to  Mikulicz,  the  increased  downward  growth  of  the  inner 
condyle  is  confined  to  the  lower  end  of  the  diaphysis.  The  prominence 
of  the  internal  condyle  is  readily  recognized  when  the  knee  is  sharply 
flexed.  It  is  a  curious  fact  that  the  deformity,  however  great,  disap- 
pears completely  when  the  knees  are  flexed.  This  is  because  the  de- 
formity is  due  to  the  greater  length  of  the  internal  condyle  so  that  the 
axis  of  the  hinge  motion  is  not  transverse  but  inclined  outward  and 
upward,  bringing  the  feet  away  from  one  another  when  the  knees  are 
extended  but  together  when  they  are  flexed.  Knock  knee,  when  well 
established,  is  treated  by  osteotomy  of  the  femur  above  the  condyles,  with 
or  without  the  removal  of  a  wedge  of  bone  (cuneiform  osteotomy),  and 
then  by  straightening  the  limb. 

Ligaments. — In  the  semiflexed  position  of  the  joint  most  of  the 
ligaments  are  relaxed,  a  condition  that  favors  the  backward  displace- 
ment of  the  tibia  by  the  contracture  of  the  hamstring  muscles,  in 
chronic  knee  joint  disease  with  flexion.  Owing  to  the  relaxation  of  the 
ligaments  in  this  position  rotary  and  slight  lateral  motion  of  the 
knee  is  allowed  in  semiflexion.  Hence  if  we  wish  to  test  the  knee  for 
abnormal  lateral  mobility,  such  as  is  due  to  rupture  of  the  lateral 
ligaments,  etc.,  the  test  should  be  made  when  the  knee  is  extended.  All 
except  the  anterior  ligaments  are  taut  in  extension,  only  the  posterior 
crucial  and  the  anterior  ligaments  are  taut  in  extreme  flexion.  The 
powerful  crucial  ligaments  are  not  relaxed  in  any  position  of  the  joint. 


FRACTURE   OF  THE  PATELLA.  455 

The  anterior  crucial  not  only  resists  hyperextension  and  anterior  dis- 
placement of  the  tibia,  i)ut  also  rotation  of  the  Ie<^  inward.  The  pos- 
terior crucial  ligament  resists  forced  Hexion  and  posterior  disi)laceuient 
of  the  tibia.  The  lateral  ligaments  lie  behind  the  center  of  the  joint, 
about  the  junction  of  its  middle  and  posterior  thirds,  hence  they  are  taut 
in  extension,  relaxed  in  flexion.  In  the  latter  j)osition  they  resist  out- 
ward rotation  of  the  tibia.  They  are  not  very  strong.  If  pus  within 
the  joint  escapes  into  the  popliteal  space  it  usually  does  so  tiirough 
the  thinnest  part  of  the  posterior  ligament,  the  part  below  the  oblique 
ligament  of  Winslow. 

AVhen  one  is  in  the  act  of  falling  backward,  or  in  any  direction 
with  the  knees  bent,  an  instinctive  effort  is  made  to  avoid  the  fall  by 
violently  contracting  the  quadriceps  to  straighten  the  knee.  By  such 
a  spa^smodlc  contraction  of  the  quadriceps  o)ic  of  four  Icjfions  may  be 
caused:  (1)  fracture  of  the  patella;  (2)  rupture  of  the  ligamentum 
patellffi  ;  (-'>)  rupture  of  the  quadriceps  tendon  ;  (4)  dislocation  of  the 
patella. 

Fracture  of  the  patella  is  the  commonest  of  these.  The  fall  ot 
the  patient  is  only  indirectly  the  cause  of  the  fracture  and  it  may  be 
the  result.  In  a  fall  on  the  bent  knee,  wdien  the  hip  is  also  flexed, 
the  tubercle  of  the  tibia  and  not  the  patella  comes  in  contact  with  the 
ground.  In  some  cases,  however,  the  patella  is  broken  by  direct 
violence  as  by  a  blow  or  fall  directly  on  the  bone.  In  over  80  per 
cent,  of  cases  the  fracture  is  due  to  muscidar  action.  The  Vuie  of  frac- 
ture is  quite  uniformly  transverse  when  due  to  muscular  action,  and 
usually  at  or  just  below  the  center  of  the  bone.  Fractures  due  to 
direct  violence  may  be  transverse,  oblique,  comminuted  or  even  longi- 
tudinal. Another  important  difference  lies  in  the  fact  that  in  direct 
fractures  there  may  be  little  or  no  separation  of  the  fragments,  in 
indirect  fractures  there  is  usually  some  and  often  considerable  separation. 
This  separation  depends  upon  the  amount  of  effusion  into  the  joint, 
combined  with  the  transverse  laceration  of  the  lateral  patellar  lif/anients. 
The  influence  of  the  latter  is  seen  in  direct  fractures,  in  which,  though 
there  may  be  considerable  effusion,  there  is  little  or  no  separation,  for 
the  lateral  patellar  ligaments  are  practically  intact.  Again  in  frac- 
tures due  to  muscular  action  the  lateral  patellar  ligaments  are  more  or 
less  extensively  torn,  but  the  scpdration  disappears  or  may  be  easily 
overcome  if  the  effusion  is  gotten  rid  of.  The  pull  of  the  quadriceps 
tendon  is  not  an  important  factor  in  the  separation  until  later  on, 
after  atrophy  of  the  muscle  occurs. 

The  rupture  of  the  lateral  patellar  ligaments  and  the  failure  of  bony 
union  are  ex})lained  by  the  inechanism  of  fracture  by  muscular  action. 
(Fig.  107.)  In  the  semiflexed  position,  in  which  the  knee  is  usually 
placed  when  the  violent  contraction  of  the  (piadriceps  occure,  only  the 
middle  of  the  back  of  the  patella  rests  on  the  trochlear  surfaw  of  the 
femur,  the  upper  and  lower  ends  of  the  bone  being  unsupportitl.  Its 
vertical  axis  is  in  line  with  the  taut  ligamentum  patelhe,  while  the  line 
of  action  of  the  violently  contracted  quadriceps  muscle  is  nearly  at 


456 


THE  LOWER  EXTREMITY. 


right  angles  to  this  axis.  The  patella  is  thus  broken  as  one  would 
break  a  stick  over  the  knee.  The  bone  gives  way  first  and,  the  force 
continuing,  the  fragments  are  separated  and  the  tear  extends  a  variable 
distance  into  the  lateral  patellar  ligaments,  on  either  side  of  the  line 
of  fracture.  The  periosteum  and  tendinous  fibers  in  front  of  the  patella 
stretch  a  certain  distance  but,  if  the  fragments  are  palled  further  apart, 

Fig.  107. 


they  give  ivai/  and  curl  back  in  front  of  one  or  both  fractured  surfaces. 
This  interpjosition  of  fibrous  tissue  between  the  fragments  prevents  the  bony 
union  of  these  surfaces  and  often  prevents  crepitus  when  the  surfaces 
are  rubbed  together.  This  is  the  reason  why  treatment  by  open  opera- 
tion, in  this  the  commonest  variety  of  fracture  of  the  patella,  is  in  such 
favor,  as  it  alone  assures  bony  union.  In  direct  fractures  I  have  se- 
cured bony  union  without  operation  and  this  result  is  by  no  means 
rare.  As  Morris  says,  a  fracture  of  the  lower  and  non-articular  end  of 
the  patella  without  injury  of  the  synovial  membrane  is  an  anatomical 
possibility,  provided  the  amount  of  separation  is  slight.  In  such  a 
case  the  fat  behind  the  lower  end  of  the  patella  saves  the  synovial  mem- 
brane from  injury.  The  patella,  which  is  a  sesamoid  bone  developed 
in  the  quadriceps  tendon,  does  not  ossify  until  the  end  of  the  second 
year  and  may  be  congenitally  absent.  Nearly  all  the  arteries  around 
the  joint  furnish  blood  sup})ly  to  it. 

Rupture  of  the  ligamentum  patellae  is  rare.  Exceptionally  the 
tendon  is  torn  from  its  insertion  into  the  tubercle  of  the  tibia,  and 
rarely  the  tubercle  is  avulsed  with  the  tendon. 

Rupture  of  the  quadriceps  tendon  above  the  patella  is  more  com- 
mon, but  rare  in  comparison  with  fractures  of  the  patella.     It  residts 


DISLOCATION  OF  THE  SEMILUNAR   CARTILAGES.  457 

from  a  violent  muscular  contraction,  sometimes  from  a  slight  one  when 
the  muscle  is  diseased.  Above  the  patella  a  well-marked  dcprea^iion 
appears  which  is  occupied  by  a  blood  clot.  Rupture  of  the  tendon  or 
ligament  is  treated  by  aseptic  suti(re.  In  these  three  forms  of  injury 
the  ability  to  extend  the  knee  is  lost  or  impaired. 

Dislocation  of  the  patella  is  rare.  The  coiniaonenl  form  is  the  ont- 
ward  dislocation  which  may  be  complete  or,  more  often,  incomplete. 
It  may  be  caused  bi/  a  blow  on  the  prominent  inner  border  or,  more 
commonly,  by  a  violent  contraction  of  the  quadriceps  muscles.  It 
occurs  most  often  in  the  extended  position  of  the  limi),  when  the  front 
of  the  capsule  and  the  ligaments  of  the  patella  are  most  lax.  The  line 
of  action  of  the  quadriceps,  in  the  axis  of  the  thigh,  is  not  the  same  as 
the  axis  of  the  patellar  ligament,  in  the  axis  of  the  leg.  W/ien  there- 
fore the  quadriceps  contracis,  the  patella,  which  lies  at  the  angle  of  meet- 
ing of  these  two  axes,  is  pulled  outu-ard,  as  the  muscle  and  ligament 
tend  to  form  a  straight  line.  In  knock  knee  therefore  the  tendency  to 
outward  dislocation  is  increased  by  the  greater  angle  between  the  muscle 
and  the  ligament.  The  outward  dislocation  of  the  patella  is  resisted 
by  the  prominent  outer  margin  of  the  trochlear  surface  of  the  femur 
and  by  the  internal  expansion  of  the  quadriceps.  The  latter  may  re- 
main intact  in  an  incomplete  dislocation,  but  must  be  ruptured  to  allow 
a  complete  outward  dislocation.  In  the  latter  the  patella  is  displaced 
to  the  outer  side  of  the  external  condyle  and  usually  lies  with  the 
inner  border  directed  forward  and  the  posterior  surface  inward.  The 
next  most  common  form  is  the  so-called  edgewise  or  vertical  dislocation 
of  the  patella.  In  the  commoner  variety  of  this  form  the  inner  border 
rests  in  or  near  the  bottom  of  the  trochlear  groove  with  the  outer  bor- 
der projecting  forward  and  the  anterior  surface  looking  inward.  The 
opposite  displacement  is  nearly  as  common.  Muscular  action,  not 
always  violent,  seems  to  be  the  most  common  cause  of  this  form  also, 
but  it  may  be  due  to  a  blow  on  the  inner  edge  of  the  bone.  Inu-ard 
dislocations  are  rare. 

The  semilunar  cartilages  are  attached  by  their  peripheral  surfaces  to 
the  capsule  and  lateral  ligaments  of  the  knee.  In  effusions  into  the  Joint 
one  sees  a  groove  in  the  bulging  capsule  on  either  side  of  the  lower  end 
of  the  patella,  due  to  the  lateral  patellar  ligaments  and  to  this  attach- 
ment of  the  semilunar  Ciirtilages,  which  incompletely  divides  the  syno- 
vial cavity  into  an  upper  larger  and  a  lower  smaller  portion.  Disloca- 
tion of  one  or  the  other  of  the  semilunar  cartilages  occurs  as  a  rule  iVi)m  a 
twist  of  the  leg  in  the  semiflexed  position  of  the  joint.  In  flexion  and 
extension  of  the  knee  the  cartilages  move  with  the  tibia,  but  in  mta- 
tion  one  or  the  other  disc  is  held  firmly  between  the  two  bones  while 
the  other  is  liable  to  slip  between  them.  Thus  in  rotation  outward, 
performed  chiefly  by  the  biceps,  the  external  meniscus  is  held  closely 
between  the  outer  condyle  and  the  tibia,  as  these  two  are  pressed 
together  by  the  biceps.  This  increases  the  ga]>  between  the  internal 
condyle  and  the  tibia  into  which  the  internal  disc  is  liable  to  slip. 
Similarly  in  internal  rotation  the  outer  disc  is  the  one  liable  to  dis- 


458  THE  LOWER  EXTREMITY. 

placemeDt.  Hence  the  rule  that  dislocation  of  the  internal  disc  occurs 
from  an  outward  twist  of  the  knee,  that  of  the  external  disc  from  an  in- 
loard  twist.  The  internal  disc  is  dislocated  more  than  three  times  as 
often  as  the  external  and  the  left  knee  is  affected  nearly  three  times  as 
often  as  the  right.  This  may  be  partly  accounted  for  by  the  fact  that 
the  external  cartilage  is  smaller,  rounder  and  more  movable  than  the 
internal,  and  is  attached  partly  to  the  posterior  crucial  ligament,  and 
thereby  to  the  femur.  The  popliteus  tendon  which  grooves  its  outer 
surface,  postero-externally,  may  also  help  to  hold  it.  The  dislocated 
cartilage  is  torn  from  its  attachment  to  the  tibia,  usually  at  one  end, 
and  is  at  times  pulled  into  the  joint  during  flexion  and  rotation,  where  it 
becomes  pinched  and  locked  between  the  two  bones,  giving  rise  to  a 
sudden  pain  and  fixation  of  the  knee  in  the  flexed  position.  On  pal- 
pating the  line  of  the  joint  we  may  feel  a  gap,  when  the  disc  is  dis- 
placed into  the  joint,  or  a  marked  ridge  when  it  is  displaced  laterally. 
The  displacement  can  usually  he  reduced,  by  extension  followed  by  sudden 
flexion  and  rotation  ;  but  an  operation  is  often  required  to  effect  a 
cure,  by  removing  the  loose  portion  or  suturing  it  in  position. 

The  synovial  membrane  of  the  knee  is  the  most  extensive  and  com- 
plicated in  the  body.  It  extends  as  a,  jwuch  between  the  quadricejis  and 
the  front  of  the  femur  for  about  an  inch  above  the  trochlear  surface  of 
the  femur  and  the  upper  end  of  the  patella.  Above  the  pouch  is  a 
bursa  (subcrural)  between  the  quadriceps  and  the  front  of  the  femur, 
over  an  inch  long  vertically,  which  communicates  with  the  pouch  in 
70  per  cent,  of  cases  in  children  and  80  per  cent,  in  adults.  The 
partition  varies  from  a  complete  septum  to  a  mere  trace.  In  the  ex- 
tended position  therefore,  we  may  find  a  synovial  cavity,  continuous 
with  the  joint,  over  two  inches  (5  to  8  cm.)  above  the  2Mtella  or  the 
trochlear  surface  of  the  femur,  so  that  a  wound  or  incision  at  this  level 
may  practically  open  into  the  joint  in  a  majority  of  cases.  In  exten- 
sion the  pouch  is  supported  by  the  subcrureus  while  in  flexion  it  is 
somewhat  drawn  down.  In  case  of  effusion  into  the  joint  the  pouch 
and  bursa  appear  as  a  median  prominence  or,  if  separate  and  both  are 
filled  with  effusion,  as  two  prominences  above  the  patella.  In  this 
condition  of  effusion  into  the  joint  the  patella  is  raised  from  the  trochlear 
surface  of  the  femur,  on  account  of  its  connection  with  the  anterior 
part  of  the  capsule,  and  is  said  to  "float.''  By  sudden  pressure  on 
the  patella  the  latter  is  made  to  strike  the  femur  producing  a  click, 
which  is  useful  as  a  diagnostic  sign  of  fluid  in  the  joint. 

The  attachment  of  the  posterior  crucial  ligament  to  the  posterior 
ligament  divides  the  synovial  cavity,  posteriorly,  into  an  inner  and  an 
outer  condylar  recess.  The  upper  third  of  the  ligamentum  patellae  is 
separated  from  the  synovial  membrane  by  a  pad  of  fat,  the  lower  two 
thirds  from  the  tibia  by  fat  and  a  bursa.  The  synovial  membrane  is 
remarkable  for  the  number  of  fringes  from  its  inner  surface,  especially 
about  the  patella.  Laceration  of  these  fringes,  followed  by  their 
infiltration  with  blood  and  their  subsequent  exfoliation,  gives  origin  to 
some  of  the  "loose  bodies''  in  the  knee  joint.     The  organization  of  an 


PLATE    LI  V. 


POPLITEUS 

TENDON 

FAT   BENEATH 

LIG.    PATELL>E 

EXT.    LATERAL 

LIGAMENT 
BICEPS     TEN- 
DON 


BURSA    BENEATH 
LIG.    PATELL/E 


FIG.    108. 


SUBCRUREUS 
MUSCLE 


ANT.   TIBIAL 
ARTERY 


SUBCRURAL 
BURSA 

QUADRICEPS 

T  L  r-i  D  O  N 


NT.    LATERAL 
PATELLAR 
LIGAMENT 


NT.    SEMI- 
LUNAR  C  AR- 
TILAGE 


INT,  HAMSTRING 
TENDONS,  WITH 
BURSA    BEN  EATH 


K  nee-joint  from  in  front,  sliowing  synovial  sac,  anterior  ligaments, 
superficial  anastomosis  of  articular  arteries,  etc.     (Testut.) 


SUBCRURAL 


PREPATELLAR 
BURSA 

LIGAMENTUM 
MUCOSUM 

LIGAMENTUM 
PATELL>E 

BURSA 


—      1,  POPLITEAL 

' .  ■' //  VEIN 

__ii_-ANT.    CRUCIAL 
T/i  LIGAMENT 

POST.     LIGAMENT 

EXT.    SEMILUNAR 

^..'l  CARTILAGE 

rj 

•_ POPLITEAL 


iF~ 


'nj  POPLITEUS 

7?  MUSCLE 


GASTROCNEMIUS 
MUSCLE 


Lateral  half  of  vertical  sagittal  section  oi'  right  knee  after  dis- 
tention of  the  synovial  sac.  Probe  i^assed  through  opening  between 
pouch  above  patella  and  subcrui-al  iDursa.     (Joessel.) 


EXCISION  OF   THE  KXEE.  459 

intra-articularcl(jt  or  of  fibrinous  deposits  in  the  joint  may  also  produce 
similar  "  loose  bodies." 

Synovitis  from  injury  or  exposure  to  cold  is  more  frequent  in  the 
knee  joint  than  elsewhere,  owing  to  its  suj)erficial  and  exposed  position. 
The  floating  of  the  patella  and  the  bulging  of  the  sac  above  at  the 
sides  of  the  })atella  have  already  been  referred  to  (see  page  4o8).  In 
chronic  in-ffdinmaf ion  of  the  knee  joint  the  latter  almost  always  assumes 
the  flexed  position  which  may  be  partly  explained  ax  fo/loirs.  (Ij  The 
capacity  of  the  joint  is  increased  on  moderate  flexion,  being  greatest 
in  flexion  to  2o°  and  least  in  com])lete  flexion.  The  knee  therefore 
assumes  the  flexed  position  to  diminish  the  tension,  which  causes 
pain  from  pressure  on  the  nerve  endings.  (2)  The  irritation  of  the 
sensory  nerves  of  the  joint  causes  a  reflex  contraction  of  the  muscles, 
which  fix  the  joint  and  prevent  motion,  as  the  latter  is  painful.  The 
flexor  muscles  are  more  powerful  and  more  favorably  placed  for  acting 
and  hence  the  joint  is  flexed.  The  flexed  position,  at  first  maintained 
by  muscular  action,  is  later  on  fixed  by  fibrous  or  bony  anchylosis. 

Excision  of  the  knee  is  sometimes  required  in  chronic  tubercular 
disease  (white  swelling),  or  in  case  of  a  knee  anchylosed  from  any 
cause  in  a  strongly  flexed  position.  Through  an  incision  from  the  hind 
part  of  one  condyle  to  that  of  the  other,  curving  below  the  patella  the 
joint  is  opened  and  the  upper  flap  turned  up.  The  internal  saphenous 
vein  and  nerve  need  not  be  divided.  AYhen  there  is  anchylosis  with 
marked  flexion  we  may  remove  a  wedge-shaped  segment  of  bone  with 
the  base  anteriorly.  In  this  way  no  undue  traction  is  made  on  the 
popliteal  vessels.  In  sawing  the  fcninr  the  section  should  be  parallel 
with  the  normal  joint  surface,  not  at  right  angles  with  the  shaft.  If 
not  properly  sawn  knock  knee  or  bow  legs  may  result.  Both  bones 
are  best  sawn  from  before  backward.  With  reasonable  care  there  is  no 
danger  of  wounding  the  popliteal  vessels,  although  there  is  more  danger 
while  sawing  the  tibia  than  the  femur  (see  p.  452).  The  operation 
should  be  done  in  such  a  way  that  the  limb  may  be  absolufcli/  straight. 
In  subjects  who  have  not  attained  their  growth  tJie  greatest  care  must 
be  taken  to  do  no  damage  to  the  epiphyseal  li)ie,  for  the  greatest  amount 
of  growth  in  length  occurs  at  this  end  of  both  bones.  The  level  of  the 
epiphyseal  line  of  the  femur  has  already  been  given  (p.  449).  The 
lower  femoral  epiphysis  unites  with  the  shaft  about  the  twentieth  year. 
The  limits  of  the  upper  tibial  epiphi/si,^  are  indicated  by  a  horizontal 
line  just  below  the  tuberosities,  behind  and  laterally,  so  as  to  include 
the  attachment  of  the  semimembranosus  and  the  facet  for  the  fibula. 
In  front  it  slants  down  on  each  side  to  meet  just  below  the  tubercle, 
which  is  included  in  the  epiphysis.  It  unites  with  the  shaft  in  the 
twenty-first  or  twenty-second  year.  Arthrectomy  of  the  knee  has 
replaced  excision  to  a  large  extent,  and   is  j)r('fcrable  in  suitable  cases. 

Disarticulation  at  the  knee  may  be  done  by  (1)  lateral  flaps  (Stephen 
Smith),  (2)  an  elliptical  incision  or  (3)  a  long  anterior  flap.  The 
best  method  is  the  first.  In  the  method  by  a  long  anterior  flap  there 
is  danger  of  sloughing  of  the  flap.    All  methods  have  the  disadvantage 


460  THE  LOWER  EXTREMITY. 

of  leaving  a  large  surface  of  cartilage  which  has  little  or  no  reparative 
action.  Hence  I  prefer  Gritti's  method,  in  which  the  lower  surface 
of  the  condyles  and  the  articular  surface  of  the  patella  are  sawn  off 
and  the  sawn  surfaces  brought  together.  The  patella  with  the  tough 
skin  covering  it  then  forms  the  lower  end  of  the  stump. 

Fractures  of  the  Lower  End  of  the  Femur. — Besides  the  frac- 
tures of  the  shaft  above  the  condyles  (see  p.  448)  we  find:  (1)  inter- 
condyloid  fractures,  (2)  fractures  of  either  condyle  and  (3)  separation 
of  the  epiphysis.  In  (1)  the  line  of  fracture  between  the  condyles 
follows  the  intercondyloid  notch  in  a  sagittal  plane  and  forms  a  T 
with  the  fracture  separating  both  condyles  from  the  shaft.  (2) 
Fractures  of  either  condyle  are  not  common  and  may  be  due  to  avul- 
sion through  the  lateral  ligaments,  direct  violence  or  the  pressure  of 
the  head  of  the  tibia.  The  fracture  line  runs  into  the  intercondyloid 
notch.  (3)  Separation  of  the  lower  epiphysis  of  the  femur  occurs 
more  often  than  tJud  of  any  otJter,  It  is  coiainonh/  due  to  great  violence, 
acting  especially  in  extending  or  abducting  the  knee.  The  separation 
here,  as  elsewhere,  takes  place  between  the  cartilage  and  the  shaft. 
The  periosteum  is  freely  stripped  up  from  the  shaft,  but  remains  attached 
to  the  epiphysis.  The  epiphysis  is  commonly  displaced  forward  and 
to  one  side,  usually  the  inner.  The  injury  is  frequently  compound. 
Direct  reposition  has  sometimes  failed,  owing  to  the  presence  of  prom- 
inent lips  on  the  epiphysis  and  to  the  tension  of  the  periosteum.  In 
such  cases  operative  reposition,  through  an  external  incision,  has  given 
good  results. 

Fracture  of  the  upper  end  of  the  tibia  is  not  common,  less  so  than 
that  of  any  other  part  of  the  bone.  It  may  be  due  to  severe  direct  or 
indirect  violence,  and  the  line  of  fracture  may  or  may  not  involve  the 
articular  surface.  Owing  to  the  proximity  of  the  knee  joint,  which 
is  often  involved  directly  or  indirectly,  an  effusion  occurs  within  the 
joint.  Separation  of  the  upper  epiphysis  of  the  tibia  has  been  observed  in 
a  few  cases.  The  upper  end  of  the  tibia  and  the  lower  end  of  the  femur 
are  favorite  situations  for  osteosarcoma. 

THE   LEG. 

As  the  limits  of  this  region  we  may  take  the  level  of  the  tubercle  of 
the  tibia  above  and  that  of  the  base  of  the  malleoli  below. 

Landmarks  and  Surface  Markings. — The  anterior  tibial  border  or 
"shin"  can  be  felt  throughout  its  entire  length.  It  is  sharp  and 
curved  outward  above  ;  rounded,  less  prominent  and  curved  inward 
in  its  lower  third,  where  it  ends  in  front  of  the  internal  malleolus. 
The  inner  border  can  also  be  felt  from  the  tuberosity  above  to  the  mal- 
leolus below.  The  internal  surface,  between  these  two  borders,  is  sub- 
cutaneous except  above,  where  it  is  covered  by  the  tendinous  insertion 
of  the  sartorius  covering  those  of  the  gracilis  and  semitendinosus. 
Although  the  liead  of  the  fibula  is  easily  felt  its  shaft  is  buried  by  the 
overlying  muscles  in  its  upper  half.     In  its  lower  half  it  becomes  pal- 


TOPOGRAPHY  OF  THE  LEG.  461 

pable,  especially  in  the  lower  four  inches,  where  the  malleolus  and  the 
triangular  surface  above  it  are  subcutaneous.  This  subcutaneous  area 
lies  between  the  peroneus  tertius  and  brevis.  Tlie  Hl>ula  is  well 
behind  the  tibia,  so  as  to  be  posterior  to  the  plane  of  the  posterior 
border  of  the  latter.  Anto-iorli/,  between  the  two  bones,  we  can  see 
the  outline  of  the  tibialis  anticus  internally,  and  that  of  the  narrower 
and  more  external  extensor  communis  digitorum  can  be  made  out 
when  in  action.  The  groove  separating  these  muscles  is  quite  distinct 
in  muscular  subjects  and  forms  the  best  guide  to  the  anterior  tibial 
artery.  In  the  lower  third  of  the  leg  the  tendon  of  the  extensor 
longus  pollicis  comes  to  the  surface  and  can  be  felt  between  these  two 
muscles.  Podcriorly  the  prominence  of  the  calf  is  mainly  formed  by 
the  gastrocnemius,  whose  two  heads  are  conspicuous  when  one  stands 
on  the  toes.  In  this  position  it  is  seen  that  the  inner  head  is  larger  and 
longer.  In  the  same  position  tlw  Achil/c.s  tendon  stands  out  in  promi- 
nent relief  from  about  the  middle  of  the  leg  to  the  heel.  The  soleus 
comes  to  view  on  either  side  of  this  tendon  but  more  especially  ex- 
ternally where  it  is  less  covered  by  the  gastrocnemius. 

Topography. — The  course  of  the  anterior  tibial  artery  is  indicated 
by  (I  fine  from  a  point  midway  between  the  head  of  the  tiljula  and  the 
prominence  of  the  outer  tuberosity  of  the  tibia  to  tlie  middle  of  the 
front  of  the  ankle  joint.  The  posterior  tibial  artery  runs  from  the 
bifurcation  of  the  popliteal,  at  the  center  of  the  lower  end  of  the  pop- 
liteal space,  opposite  the  lower  end  of  the  tubercle  of  the  tibia  and 
about  two  inches  below  the  joint,  to  the  mid-point  of  a  line  from  the  tip 
of  the  internal  malleolus  to  the  lower  and  inner  corner  of  the  prom- 
inence of  the  heel.  At  this  point  the  artery  bifurcates  into  the  two 
plantar  arteries.  About  an  inch,  sometimes  less  (lo  mm.),  below  its 
upper  end  the  posterior  tibial  gives  off  the  peroneal  artery,  which  runs 
along  the  inner  border  of  the  fibula  to  about  an  inch  above  the  ankle 
joint,  where  it  gives  off  the  anterior  peroneal. 

The  internal  saphenous  vein,  arising  from  the  venous  arch  on  the 
dorsum  of  the  foot,  rutis  in  front  of  the  internal  malleolus  and  thence 
just  behind  the  internal  border  of  the  tibia  to  the  level  of  the  knee, 
where  it  lies  just  behind  the  internal  condyle.  The  short  saphenous 
vein  passes  behind  the  external  condyle  and  thence  up  the  back  of  the 
leg  to  the  lower  ])art  of  the  ham  where  it  perforates  the  deep  fascia. 
Both  the  internal  and  external  saj)henous  veins,  but  more  esj)eoially 
the  former,  are  visible  beneath  the  skin  unless  the  subcutaneous  fat  is 
very  abundant.  Both  of  the  saphenous  veins  and  of  the  tibial  arteries 
are  accompanied  by  nerves  of  the  same  name. 

The  skin  of  the  leg,  especially  anteriorly,  is  n)ore  adherent  to  the 
deep  fascia  than  that  of  th(>  thigh.  Thus  in  circular  amputations  it 
is  necessary  to  dissect  up  the  skin  Hap  and  not  merely  to  retract  it. 
Owing  to  the  conical  shape  of  the  leg  it  may  be  difficult  or  impossible 
to  dissect  back  this  skin  flap  without  sj)litting  it  on  one  side  in  the 
form  of  a  cuff.  The  sul)cutaneou.M  tissue  oi'  the  leg,  especially  in  front, 
contains  comparatively  little  fat,  so  that  the  >^kiu  over  the   inner  sur- 


462  THE  LOWER  EXTREMITY. 

face  of  the  tibia  lies  nearly  directly  on  the  hone.  The  skin  is  here  ex- 
posed to  blows  and  kicks,  which  produce  a  degree  of  pain,  bruisino^  or 
cutting  far  in  excess  of  what  a  similar  violence  would  produce  else- 
where. Llcers  and  eczema,  as  the  result  of  varicose  veins,  are  common 
in  front  of  the  leg  and  run  a  very  chronic  course.  Ulcers  over  the 
bone  may  expose  the  latter,  lead  to  disease  of  its  surface  and  result  in 
scars  that  are  adherent  to  the  bone. 

In  the  subcutaneous  tissue  lie  the  superficial  veins,  nerves  and  lym- 
phatics. The  loiifj  saijheiionx  vein  is  not  infrequently  double  in  the  leg, 
the  second  trunk  lying  behind  the  regular  course  of  the  first  trunk 
(see  p.  461),  that  is  further  behind  the  internal  border  of  the  tibia. 
Most  of  the  superficial  lymph  vessels  accompany  the  long  saphenous 
vein  and  the  majority  of  them  are  in  front  of  it,  while  the  long  saph- 
enous nerve  usually  lies  behind  and  deeper  than  the  vein.  A  few 
superficial  lymph  vessels  accompany  the  short  or  external  saphenous 
vein  to  the  small  popliteal  nodes.  The  latter  lymph  vessels  and  the 
short  saphenous  vein  and  nerve  are  covered  by  a  duplication  of  the  deep 
fascia  so  that  they  are  not  strictly  in  the  subcutaneous  tissue.  The 
musGulo-cutaneous  nerve  perforates  the  deep  fascia  near  the  septum  be- 
tween the  peroneal  and  extensor  muscles  at  the  upper  end  of  the  lower 
third  of  the  leg.  Thence  it  runs  downward  and  inw^ard  in  the  sub- 
cutaneous tissue^  so  superficially  that  it  is  easily  palpable,  or  even 
visible  in  thin  subjects. 

The  deep  fascia  closely  invests  the  leg  and  in  its  upper  third  is 
adherent  to  the  underlying  muscles.  Although  it  is  attached  to  the 
anterior  and  internal  borders  of  the  tibia  it  is  not  wanting  over  its 
internal  surface,  as  stated  by  Tillaux,  but  continues  over  this  surface 
more  or  less  adherent  to  its  periosteum.  It  is  attached  to  the  head  and 
the  malleolus  of  both  tibia  and  fibula  and  is  continuous  with  the  fascia 
lata  above  and  the  annular  ligaments  and  the  fascia  of  the  foot  below. 
Tu:o  sejjta  passing  inw'ard  from  the  deep  surface  of  this  fascia,  to  be 
attached  one  to  the  anterior  and  one  to  the  external  border  of  the 
fibula,  enclose  a  compartment  which  lodges  the  peroneal  muscles  and  sep- 
arates an  anterior  from  a  posterior  compartment,  externally.  These 
two  main  compartments  are  further  separated  by  the  bones  and  inter- 
osseous ligament.  The  pjosterior  compartment  is  subdivided  into  a  super- 
ficial and  a  deep  portion  by  a  fibrous  septum,  the  deep  transverse  fascia, 
which  stretches  across  from  the  internal  border  of  the  tibia  to  the  pos- 
tero-internal  border  of  the  fibula.  There  is  an  aponeurotic  expansion 
in  the  substance  of  the  soleus,  also  connected  with  the  internal  border 
of  the  tibia,  which  may  be  mistaken  for  the  deep  transverse  fascia  in 
cutting  through  the  soleus  to  expose  the  posterior  tibial  artery. 

The  muscles  lodged  in  the  anterior  compartment  are  so  compressed 
within  their  osseo-aponeurotic  walls  that  they  form  a  protrusion  or 
hernia  when  the  fascia  is  torn  or  cut.  The  jjlantaris  tendon  has  not 
infrequently  been  rupAured,  producing  a  sudden  sharp  pain  in  the  calf. 
The  tendo  Achillis  has  been  ruptured  ([\\vmg  violent  exertion,  especially 
at  its  narrowest  and  weakest  point,  about  1|  inches  above  its  inser- 


PLATE    LV 


INT.  SAPHENOUS 
VEIN 

TIBIALIS    POST.         rl'i*^, 
MUSCLE 
DEEP  TRANS- 
VERSE   FASCIA 


POST.   TIBIAL        _    __^ 

ARTERY    ANdQ/7 

NERVE       ^'Vf 

PERONEAL — XXIA 

ARTERY 


EXTENSOR    COM. 

DIG.   MUSCLE 
.INTEROSSEOUS 
MEMBRANE 
jLjn  —     v.M      PERONEUS    LON- 

»^t^^  J'l^^ak'^vr  '''"=  MUSCLE 

fe^^SW^P>x^i\      !^      i_iiS    V.^\  !  NERVE,    ART- 
i-         ^-' y*  Ip-    ,    V  ^'^'.   f^     .  ERYANOVEIN 


CCP    TASCIA 
OF    LEG 


Cross   section    of   the    lower   end.   of   the   upper   third   of  the 
right  leg.     Lower  segment  of  the  section.     (Tiilaux.) 


GASTROCNEMIUS 
MUSCLE 


DEEP  LAYER 
3F    CRURAL 
FASCIA 


INT.    SAPHE 

NOUS    VEIN     / 
INT.    SAPHE- 
NOUS   NERVE 


PLANTARIS 
TEN  DON 


—  POST.   TIBIAL 
NERVE 
POST.   TIBIAL 
ARTERY 


Internal    aspect   of  the    lower    half  of  right   leg. 
Superficial  dissection.     (Joessel.) 


VARICOSE   VEIXS.  463 

tion  or  opposite  the  internal  malleolus.  But  more  often  it  ref|iiires 
tenotomy  on  account  of  its  contracture.  This  is  he.sf  (Jour  oj)positc  its 
narrowest  point  by  introducing^  tlu'  tenotome  in  front  of  the  tendon  at 
its  inner  margin  to  avoid  the  posterior  tibial  vessels,  and  then  cutting 
toward  the  surface.  The  posterior  tihial  V('Ji,se!t<,  however,  lie  beneath  the 
deep  transverse  fascia  and  so  far  forward  that  they  are  in  no  danger  of 
injury  with  ordinary  care.  The  xJiort  saplicnons  rein  is  near  and  usually 
in  front  of  the  outer  margin  of  the  tendon  and  may  possiblv  be 
wounded.  Its  accompanying  nerve  is  usually  in  front  of  the  vein  at 
this  point.     On  section  the  tendon  retracts  with  its  sheath. 

The  Vessels. — The  anterior  tihial  aufJ  the  peroneal  arteries,  from 
their  close  relations  with  the  tibia  and  fibula  respectively,  are  lial)leto 
be  injured  in  fradare  of  these  bones.  I  have  seen  gangrene  of  the 
foot  follow  the  rupture  of  the  anterior  tibial  artery,  in  a  bad  fracture  ot 
the  tibia.  The  anterior  tibial  artery  lies  on  the  interosseous  membrane 
in  the  upper  two  thirds  and  in  front  of  the  tibia  in  the  lower  third. 
It  lies  /?(,  the  jird  interiimsciilar  interval  on  the  outer  side  of  the  til)ia, 
but  the  whitish  line,  which  is  said  to  indicate  this  interval  on  the  sur- 
face, is  usually  indistinct  and  often  absent.  The  posterior  tibial  artery 
in  the  upper  two  thirds  of  the  leg  is  covered  by  the  inner  head  of  the 
gastrocnemius  and  the  soleus,  the  former  of  which  must  be  retracted 
inward,  the  latter  divided  to  reach  the  artery.  T/ie  incision  is  carried 
three  quarters  of  an  inch  behind  the  inner  border  of  the  tibia,  where 
the  long  saphenous  vein  is  to  be  avoided.  The  artery  is  covered  by  the 
deep  transverse  fascia  in  all  parts  of  the  leg,  so  that  this  as  well 
as  the  deep  fascia  must  be  divided  to  expose  it.  In  the  lower 
third  of  the  leg  it  becomes  more  superficial,  being  covered  only  by 
skin  and  fasciae  (two  layers),  and  in  thin  persons  it  can  be  felt 
pulsating  in  the  hollow  on  the  inner  side  of  the  tendo  Achillis. 
The  peroneal  artery  in  the  greater  part  of  its  course  is  covered  by 
the  flexor  longus  hallucis,  which  must  be  divided  or  retracted  in  order 
to  reach  it.  This  artery  also  is  beneath  the  deep  transverse  fjiscia. 
The  peroneal  artery,  by  anastomotic  branches  at  the  lower  end  of  the 
leg,  takes  the  place  of  the  posterior  and  anterior  tibial  arteries  when 
the  latter  are  rudimentary  or  wanting.  The  hifurcatio)!  of  the  jK)|)li- 
teal,  or  sometimes  that  of  the  short  tibio-peroneal  trunk,  is  where  einlxtli 
are  apt  to  lodge.  If  (janr/rene  results,  as  not  infrequently  hapi)ens,  the 
embolus  is  probably  at  the  bifurcation  of  the  popliteal,  for  in  this  case 
all  three  trunks  are  blocked. 

According  to  Joessel,  not  only  the  two  regular  venae  comites  but 
other  veins,  anastomosing  across  the  artery,  accompany  the  posterior 
tibial  and  increase  the  difficulty  of  its  ligation.  Verneuil  thinks  that 
the  deep  veins  of  the  leg  are  more  often  varicosi'  than  those  of  the 
surface,  and  that  this  condition  is  indicated  by  aching  of  the  legs  and 
swelling  of  the  feet  in  those  who  stand  a  great  deal. 

Varicose  veins  are  more  commo)i  in  the  leg  than  elsewhere,  with 
the  possible  exception  of  the  spermatic  and  hemorrhoidal  veins.  This 
fact  may  be  partly  accounted  for  In/  ( 1)  the  length  of  the  veins  of  the 


464  THE  LOWER  EXTREMITY. 

lower  extremity,  (2)  the  action  of  gravity  in  resisting  their  upward  flow 
and  in  affecting  the  weight  of  the  blood  column  which  the  valves  have 
to  support,  (3)  the  loose  support  of  the  superficial  veins  and  the  lack 
of  the  assistance  of  muscular  contraction,  and  (4)  the  liability  to  com- 
pression, within  the  abdomen,  of  the  iliac  trunk  into  which  they  ulti- 
mately enter.  The  saphenous  veins  are  also  thin-walled  and  lie  outside 
of  the  firm  deep  fascia,  and  the  long  saphenous  is  liable  to  be  affected 
by  the  use  of  garters.  Varicose  veins  are  enlarged  not  only  in  diame- 
ter but  in  length,  hence  their  tortuous  course.  The  contour  is  irregular 
and  nodular  and  the  nodules,  or  enlargements  of  the  vein,  are  found 
especially  just  above  the  valves  and  at  points  where  the  vein  is  joined 
by  deep  veins.  At  the  latter  points  pressure  is  exerted  from  three 
directions,  (1)  the  weight  of  the  blood  column  above,  (2)  the  blood 
current  and  the  resistance  of  the  valve  next  below  and  (3)  the  inflow 
from  the  side,  the  force  of  which  is  increased  by  muscular  contraction. 

The  Bones  of  the  Leg. — The  tibia  bears  the  entire  superincumbent 
weight.  The  fibula,  besides  affording  attachment  to  muscles,  plays  an 
important  part  in  the  ankle  joint  and  serves  as  a  brace  for  the  tibia, 
which  increases  its  resistance  to  lateral  strains.  The  smallest  and 
weaked  jMirt  of  the  tibia  is  at  the  junction  of  the  middle  and  lower 
thirds,  which  accordingly  is  where  most  indirect  fractures  occur. 

Direct  fractures  of  the  shaft  of  the  tibia  may  occur  at  any  point 
and  are  often  more  or  less  transverse  so  that  there  is  little  if  any  dis- 
placement. If  the  fibula  is  broken  at  the  same  time,  as  it  is  likely  to 
be,  the  fractures  of  the  two  bones  are  about  on  tlie  same  level.  The 
long,  slender  fibula,  placed  as  it  is  on  the  more  exposed  aspect  of  the 
leg,  would  apparently  be  more  often  broken  from  direct  violence  but 
for  its  covering  of  muscles.  When  one  bone  alone  is  broken  the  other 
acts  as  a  splint  and  limits  its  displacement. 

Indirect  fractures  are  due  especially  (1)  to  a  bending  or  flexion  or 
(2)  to  violence  combined  with  torsion  of  the  limb.  In  (-?)  tlie  frac- 
ture may  be  at  any  point  and  is  more  or  less  transverse  and  dentated, 
hence  there  is  little  but  angular  deformity.  In  (2)  the  fracture  is  mostly 
in  the  upper  end  of  the  lower  third  (the  weakest  part)  and  is  oblique, 
the  line  of  fracture  usually  running  downward,  inward  and  forward. 
The  fibula,  which  is  almost  always  broken  in  indirect  fractures,  breaks 
as  a  rule  at  a  higher  level.  The  sharp  lower  end  of  the  upper  fragment 
of  the  tibia  is  liable  to  puncture  the  skin  and  compound  the  fracture 
from  within.  In  one  variety  of  this  form  of  fracture,  first  described 
by  Gosselin,  the  sharp  ends  of  both  fragments  end  in  a  triangular 
point  and  from  the  bottom  of  the  depression  in  the  lower  fragment, 
corresponding  to  the  point  of  the  upper  fragment,  a  fissure  runs 
sj)irally  downward  and  often  enters  the  ankle  joint. 

Owing  to  the  subcutaneous  position  of  the  tibia  its  fractures  are 
frejjuerdly  compounded,  from  within  in  indirect  fractures,  from  without 
or  within  in  direct  fractures.  On  the  subcutaneous  inner  surface  and 
anterior  border  we  can  detect  even  very  slight  displacements  as  well 
as  other  pathological  conditions.     In  oblique  fractures  the  lower  frag- 


LANDMARKS  OF  THE  ANKLE.  465 

ment  is  often  drawn  upward  and  outward,  behind  ilie  upper,  by  the  calf 
muscles  and  rotated  outward  hy  the  weight  of  the  foot,  which  has  lost 
its  continuity  witii  tiie  upper  leg 

The  tibia,  more  tlian  any  other  bone,  l;ecomes  bent  in  ciiildren  with 
rickets.  The  bowing,  "  bow-legs,"  is  xitnudly  oatward,  at  times  asso- 
ciated with  or  replaced  by  a  forward  one.  It  is  caused  by  a  tonic  con- 
traction of  the  muscles  and  is  increased  by  the  weight  of  the  child  in 
walking.  It  is  generally  mod  prominent  at  the  weakest  part  of  the 
bone,  the  junction  of"  the  lower  and  middle  thirds. 

In  amputation  of  the  leg  in  the  upper  third  the  "place  of  election  "  is  a 
hand's  breadth  below  the  knee  joint.  This  point  was  chosen  as  giving 
a  convenient  length  of  leg  stump  for  wearing  a  peg  leg;  for  the  knee 
is  then  bent  and  the  weight  is  borne  on  the  tubercle  of  the  til)ia. 
This  line  of  amputation  is  at  or  just  above  the  large  nutrient  artery  of 
the  tibia,  which  therefore  does  not  cause  trouble,  as  it  may  below.  ^It 
this  level  three  arterial  trunks  are  met  with  for  the  tibio-peroneal  trunk 
bifurcates  three  inches,  or  slightly  less,  below  the  knee  joint.  Through- 
out the  leg  the  two  posterior  arteries  are  beneath  the  deep  transvei'se 
fascia,  or  in  a  duplication  of  it,  the  peroneal  behind  the  fibula,  the 
posterior  tibial  behind  the  tibia  and  separated  from  it  by  the  tibialis 
posticus  and  the  flexor  longus  digitorum.  The  anterior  tibial  is  to  be 
sought  in  front  of  the  interosseous  membrane  in  the  upper  two  thirds 
and  in  front  of  the  tibia  below  this.  In  the  upper  third  of  the  leg  am- 
putatlon  by  long  external  flap  is  the  best  method,  provided  care  is  used 
to  preserve  the  anterior  tibial  artery  to  the  end  of  the  flap,  and  not  to 
bare  the  bone  so  high  as  to  run  the  risk  of  injuring  this  artery  where 
it  comes  forward  above  the  interosseous  membrane.  Circular  ampu- 
tation is  also  suitable  in  the  upper  half,  but  less  so  below,  on  account 
of  the  conical  shape  and,  in  the  lower  third,  the  lack  of  a  muscular 
covering.  //*  tlie  middle  third  amputation  by  a  lone/  posterior  jlaj>,  in- 
cluding (1)  the  superficial  layer  of  muscles  (Lee)  or  both  superficial 
and  deep  muscles  (Hey),  is  a  favorite  method.  Owing  to  the  danger 
of  injury  to  the  covering  skin  from  the  pressure  of  the  sharp  angle  of 
the  shin,  after  sawing  the  tibia,  this  angle  should  always  be  bevelled  ofl'. 

THE    ANKLE. 

The  limits  of  this  region  are  artificial  and  may  be  placed  two  fingers' 
breadth  above  an<l  below  the  malleoli. 

Landmarks  and  Surface  Markings. — The  two  malleoli  are  promi- 
nent and  very  distinctly  outlined.  Tlie  external  lies  opjiosite  the 
center  of  the  joint,  descends  lower  by  half  an  inch,  is  slightly  less 
prominent  and  is  half  an  inch  behind  the  i)nter  malleolus.  ]l»ut  as  the 
latter  is  broader  antero-posteriorly  tlie  posterior  borders  of  the  two  are 
on  the  same  level.  The  tip  of  tiie  external  malleolus  lies  opposite  the 
posterior  caleaneoscaphoid  joint.  According  to  Holden  the  inner  edge 
of  the  patella,  the  internal  malleolus  and  the  inner  side  of  the  great 
toe  should  be  in  the  same  vertical  plane,  a  fact  to  be  noticed  in  setting 
30 


466  THE  LOWER  EXTREMITY. 

fractures.  In  front  of  the  ankle  the  extensor  tendoTis  form  a  prominence, 
which  is  very  marked  when  they  are  in  action  in  flexion  of  the  ankle. 
From  within  outward  we  can  distinguish  the  tendons  of  the  tibialis 
anticus  (the  most  superficial),  the  extensor  longus  hallucis  and  the 
extensor  longus  digitorum,  with  the  peroneus  tertius.  On  either  side 
of  the  prominence  due  to  the  tendons  and  in  front  of  each  malleolus  is 
a  sU[/ht  f?(y;r&s-.s'/o>?.  Opposite  the  joint  line  this  depression  corresponds 
to  the  thin  anterior  part  of  the  capsule  and  hence  it  is  rejjlaced  by  a 
bulging  in  sprains,  effusions  into  the  joint,  tubercular  disease  of  the 
latter,  etc.  The  tendo  Achillis  forms  a  marked  prominence  behind. 
On  either  side  of  it,  between  it  and  the  malleolus,  is  a  marked  furroic. 
Along  the  inner  furrow,  behind  the  inner  margin  of  the  tibia  and 
the  back  of  the  malleolus,  the  tendon  of  the  tibialis  posticus  can  be 
felt  and  behind  and  external  to  it  that  of  the  flexor  longus  digitorum. 
Behind  the  extei^nal  mcdleolus  the  long  and  short  peroneal  tendons  are 
palpable,  the  tendon  of  the  brevis  being  nearer  to  the  bone. 

Topography. — The  line  of  the  ankle  joint  is  half  an  inch  above  the 
tip  of  the  internal  malleolus.  Opposite  the  bend  of  the  ankle  the  an- 
terior tibial  artery  becomes  the  dorsalis  pedis  and,  with  the  anterior 
tibial  nerve,  lies  between  the  tendons  of  the  extensors  longus  hallucis 
and  longus  digitorum,  where  its  pulsation  can  be  felt.  The  line  of  the 
artery  is  from  the  middle  of  the  ankle  to  the  proximal  end  of  the 
interval  between  the  first  and  second  metatarsal  bones.  In  some  cases 
it  describes  a  curve,  concave  internally.  The  posterior  tibial  artery 
and  nerve  lie  behind  the  internal  malleolus,  external  and  a  little  pos- 
terior to  the  tendon  of  the  flexor  longus  digitorum.  The  tendon  of 
the  flexor  longus  pollicis  lies  still  more  externally,  at  the  back  of  the 
lower  end  of  the  tibia,  midway  between  the  two  malleoli.  The  pos- 
terior tibial  artery  bifurcates  into  the  two  plantar  arteries  opposite  the 
raid-point  of  a  line  between  the  tip  of  the  internal  malleolus  and  the 
lower  and  inner  corner  of  the  prominence  of  the  heel.  The  long 
saphenous  vein  ascends  iu  front  of  the  internal  malleolus,  the  short 
saphenous  behind  the  external  malleolus. 

The  skin  covering  this  part  is  thin  and  loosely  attached,  and  rests  al- 
most directly  upon  the  bones,  with  the  interposition  of  but  very  little 
subcutaneous  tissue.  Hence  it  is  readily  contused  or  excoriated,  as  for 
instance  by  ill-fitting  splints ;  and  gangrene  may  result  from  slight 
pressure.  Thus  I  have  seen  gangrene  of  the  skin  over  the  malleolus 
result  from  pressure  against  the  bed  in  sleeping,  in  the  case  of  an  old  gen- 
tleman who  had  previously  lost  a  toe  from  senile  gangrene.  The  sub- 
cutaneous connective  tissue  is  abundant  only  in  front  and  at  the  sides  of 
the  tendo  Achillis,  and  only  here  is  there  any  considerable  amount  of 
fat.  The  deep  transverse  fascia  of  the  leg  is  continued  down  behind 
the  tendons  and  vessels  at  the  back  of  the  internal  malleolus.  This 
fascia  and  a  considerable  amount  of  loose  connective  tissue  and  fat 
separate  these  structures  from  the  tendo  Achillis,  so  that  in  the  teno- 
tomy of  the  latter  there  is  little  or  no  danger  of  wounding  the  pos- 
terior tibial  vessels. 


PLATE    LVI 


FIG.  112. 


The  anterior  annular  ligament  of  the  ankle  and 
the  synovial  membi-anes  of  the  tendons  beiaeath  it 
artificially  distended.     (Gerrish,  after  Testut. ) 


SYNOVIAL  SHEATHS  AT  THE  ANKLE.  407 

The  deep  fascia,  continuous  with  that  of  the  leg  above  and  the  foot 
below,  is  reinforced  in  fnjnt  and  laterally  so  as  to  form  Jinn  baruh, 
known  as  annular  ligaments,  whicli  bind  down  and  keep  in  plar-e  the 
tendons  in  these  situations.  Tiiere  are  two  anterior  annular  ligaments 
of  which  the  upper  passes  transversely  between  the  anterior  borders  of 
the  tibia  and  fibula  and  keeps  in  place  the  anterior  tendons  in  the 
slender  lower  third  of  the  leg.  The  lower  band  begins  on  the  outer 
side  of  the  calcaneus  and  splits  into  two  layers,  which  pass  one  behind 
and  one  in  front  of  the  tendons  of  the  peroneus  tertius  and  extensor 
longus  digitorum  and  then  unite  at  the  inner  border  of  the  latter.  It 
again  divides  into  two  branches,  of  which  the  upper  goes  to  the  front 
of  the  internal  malleolus,  the  lower  to  the  scaphoid  and  the  plantar 
fascia.  This  ligament  biiKhdovra  the  tendons  at  the  bend  of  the  ankle 
and  prevents  them  from  projecting  forward  Avhen  in  action.  The  lateral 
annular  ligaments  connect  the  back  of  the  malleoli  with  the  calcan(  um 
on  the  corresponding  side  and  prevent  the  dislocation  forward  of  the 
tendons  behind  these  two  malleoli.  As  the  result  of  violence  these 
lateral  bands  may  be  ruptured,  allowing  one  or  more  tendons  to  be  r//.s-- 
located  foricard  onto  the  front  of  the  corresponding  malleolus.  This 
has  happened  to  the  tibialis  posticus  and  peroneus  longus,  and  the  latter 
is  more  often  displaced  than  any  tendon  in  the  body.  From  the  deep 
surface  of  the  internal  annular  ligament  processes  pass  forward  to  bony 
ridges  at  the  back  of  the  malleolus  and  the  lower  end  of  the  tibia,  thus 
forming  separate  compjartiaents  for  each  of  the  three  tendons  here.  Thus 
it  happens  that  the  tibialis  posticus  tendon  may  be  displaced  without  the 
other  two,  which  are  further  from  the  inner  surface  of  the  malleolus. 

In  passing  beneath  the  two  lateral  and  the  lower  anterior  annular 
ligament  the  tendons  are  pjrovldcd  icith  separate  sjmovial  sheaths,  except 
that  there  is  a  common  sheath  for  the  two  peroneal  tendons  and  for 
those  of  the  extensor  longus  digitorum  and  peroneus  tertius.  The 
si/novinl  sheath  of  the  tibialis  anticus  extends  from  5-0  cm.  above  the 
ankle  joint  nearly  to  the  first  metatarsal  bone ;  that  of  the  peroneal 
tendons  from  3-4  cm.  above  the  joint  to  the  calcaneo-cuboid  joint ; 
that  of  the  extensor  longus  digitorum  and  peroneus  tertius  from  2  cm. 
above  to  4-5  cm.  below  the  joint ;  that  of  the  extensor  longus  hallucis 
from  1  cm.  above  the  joint  nearly  to  the  metatarsus;  that  of  the 
tibialis  posticus  from  5  cm.  above  the  inner  malleolus  to  the  scaphoid, 
and  that  of  the  flexor  longus  digitorum  from  3  cm.  above  the  malleolus 
to  the  sole  of  the  foot,  where  it  is  crossed  by  the  extensor  longus  hal- 
lucis and  communicates  with  its  sheath.  These  .synovial  .sheathif  may 
become  injiamed  and  filled  with  fluid  and,  as  at  the  wrist,  this  inflam- 
mation may  be  tubercular,  with  or  without  the  formation  of  "rice 
bodies."  I  have  removed  a  large  mass  the  size  of  an  egg,  due  to 
tubercular  inflammation  of  the  extensor  tendons  in  front  of  the  ankle. 
The  long  tumor,  due  to  an  eff'usion  into  one  of  these  synovial  sheaths, 
is  often  constricted  where  it  passes  beneath  the  annular  ligament.  In- 
flammation of  the  sheath  of  the  tibialis  posticus  may  extend  to  the 
ankle  joint,  with  which  it  is  in  close  relation. 


••>/ 


468  THE  LOWER  EXTREMITY. 

Beneath  the  extensor  tendons  one  finds  a  second  layer  of  fascia  which 
separates  them  from  the  ankle  joint  and,  further  forward,  covers  the 
extensor  brevis  digitorum  muscle.  The  dorsalis  pedis  artery  and 
the  accompanying  anterior  tibial  nerve  lie  beneath  this  second  layer  of 
fascia,  which  must  be  divided  to  reach  them.  In  sprains,  fractures 
and  dislocations  of  the  ankle  these  synovial  sheaths  are  apt  to  be  torn 
and  filled  with  eiFused  blood,  and  the  long-abiding  stiffness  after  such 
injuries  is  in  part  due  to  these  injuries  of  the  sheaths,  and  the  result- 
ing adhesions.  Of  the  tendons  about  the  ankle  the  teiido  Achillis  and 
the  peroneal  tendons  are  quite  subject  to  contracture,  the  extensor  tendons 
less  so  and  the  tendons  behind  the  internal  malleolus  still  less. 
These  contractures  of  the  tendons  lead  to  various  deformities  of  posi- 
tion of  the  foot,  known  as  club-foot,  and  the  affected  tendons  require 
division  (tenotomy)  to  correct  the  deformity.  The  rupture  and  tenot- 
omy of  the  tendo  Achillis  has  already  been  described  (pp.  462—3). 
The  tibialis  posticus  tendon  may  be  divided  (1)  two  inches  above  the 
internal  malleolus,  which  is  above  its  synovial  sheath  and  where  the 
tendon  is  further  from  the  artery  than  below.  The  knife  is  entered  close 
to  the  inner  border  of  the  tibia.  (2)  It  may  be  divided  a  little  below 
and  in  front  of  the  inner  malleolus,  between  the  internal  annular  ligament 
and  the  scaphoid  bone.  The  tibialis  anticus  may  be  divided  at  the  latter 
point  with  the  posticus,  or  a  little  above  its  insertion  into  the  internal 
cuneiform.  The  tendon  of  a  sound  muscle  may  be  joined  to  that  of  a 
paralyzed  one  (tendon  grafting)  to  prevent  a  deformity  and  restore 
certain  movements  of  the  foot.  The  tendons  of  the  ankle  are 
not  infrequently  ruptured  through  violence,  especially  the  tendo 
Achillis. 

A  bursa  is  situated  between  the  tendo  Achillis  and  the  os  calcis,  rising 
about  half  an  inch  above  the  latter  and  bulging  on  either  side  of  the 
former,  when  inflamed.  Such  inflammation,  due  to  excessive  walking, 
an  injury  or  a  badly  fitting  shoe,  may  simulate  ankle  joint  disease  and, 
if  suppurative,  lead  to  caries  of  the  os  calcis.  Bursse  may  develop 
from  pressure  over  the  malleoli,  especially  the  external,  as  in  tailors 
who  sit  cross-legged. 

The  dorsalis  pedis  artery  from  its  superficial  position  is  frequently 
divided  in  wounds  or  ruptured  in  severe  contusions  while  the  posterior 
tibial  is  well  protected  from  injury  by  the  prominent  malleolus,  the 
neighboring  tendons  and  the  annular  ligament.  The  dorsalis  pedis 
artery  may  be  compressed  against  the  underlying  bones  and  its  pidsation 
may  be  sought  for,  to  determine  the  condition  of  the  artery  and  of  the 
pulse,  in  senile  gangrene  and  in  suspected  embolism  at  the  bifurcation 
of  the  popliteal. 

The  ankle  joint  owes  its  strength  to  the  strength  of  the  lateral  liga- 
ments and  the  many  closely  applied  tendons,  as  well  as  to  the  mortise 
and  tenon  shape  of  the  bony  surfaces.  The  anterior  and  posterior  lig- 
aments are  unimportant  and  so  thin  that  effusion,  when  it  occurs  within 
the  joint,  is  first  noticeable  in  front  as  a  fluctuating  bulging,  beneath 
the  extensor  tendons  and  especially  on  either  side  of  them  in  front  of 


PLATE    LVI  : 

FIG.    113. 


Tiie  internal  annular  ligament  of  the  ankle  and 
the  artificially  distended  synovial  membranes  of  the 
tendons    ^A'hich    it    confines.      (Gerrish,    after   Testut.) 


FIG.    n4. 


The  extei-nai  annular  ligament  of  tlie  ankle  and 
the  ai'tificially  distended  synovial  membranes  of  the 
tendons    which    it   confines.      (Gerrish,    after  Testut.) 


DISLOCATIOSS  OF  THE  AXKLE.  469 

the  malleoli.  This  bulging  is  the  more  marked  because  the  synovial 
membrane  forms  somewhat  of  a  pouch  anteriorly  and  posteriorly. 
Tfie  bulgiiiy  in  front  of  the  external  maUeolna  is  the  heat  point  to  opin 
or  inject  the  joint.  When  the  effusion  is  more  marked  it  may  be  evi- 
dent behind,  as  a  bulging  of  the  posterior  })art  of  the  capsule,  which 
gives  rise  to  fluctuation  on  either  side  of  the  tcndo  Achillis. 

The  ankle  joint  proper  is  a  true  hinge  joint  and  normally  allows 
no  lateral  motion,  except  passively  in  extreme  extension  (plantar  flexion) 
when  the  narrower  part  of  the  upper  surface  of  the  astragalus  is  in 
the  widest  part  of  the  tibiofibular  mortice.  The  ankle  should  i>e 
tested  for  lateral  motion  irith  the  foot  Jiexed  nearly  to  a  right  angle,  care 
being  taken  to  grasp  the  astragalus,  and  not  the  calcaneum,  by  the 
thumb  and  fingers  directly  below  and  in  front  of  the  two  malleoli.  It 
the  foot  is  grasped  a  little  lower,  over  the  calcaneum,  lateral  motion  is 
obtained  between  the  astragalus  and  calcaneum.  Lateral  movement  at 
the  ankle  joint  indicates  disease  or  injury  of  the  joint.  On  account  of 
its  superficial  and  exposed  position  iniiammaiion  of  the  ankle  not  uncom- 
monly results  from  injury.  As  the  position  of  the  joint  does  not 
affect  its  capacity  and  the  flexor  and  extensor  muscles  about  balance 
one  another,  the  foot  does  not  assume  any  characteristic  position  when 
the  ankle  is  inflamed. 

Although  sprains  of  the  ankle  are  considered  common,  Landerer  has 
expressed  the  opinion  that  95  per  cent,  of  so-called  sprains  are  frac- 
tures. This  is  probably  literally  true  if  we  count  as  fractures  those 
cases  where,  instead  of  a  tear  of  the  ligament,  a  small  portion  of  bone 
is  avulsed  at  its  attachment. 

The  ankle  joint  may  be  dislocated  so  that  the  foot  is  displaced  back- 
ward, forward,  inward  or  outward.  Only  the  antero-posterior  forms 
are  pure  dislocations,  the  lateral  forms  being  associated  with  fracture 
of  one  or  both  bones  of  the  leg  at  the  ankle. 

Dislocation  of  the  foot  backward  is  usually  due  to  extreme 
plantar  flexion  and  the  establishment  of  a  new  center  of  motion  be- 
tween the  hind  margin  of  the  tibia  and  the  astragalus,  so  that  con- 
tinued movement  ruptures  the  lateral  and  anterior  ligaments,  and  then 
the  foot  is  pushed  backward  or  the  tibia  forward.  It  may  also  be  due 
to  great  force  applied  to  either  the  foot  or  leg  while  the  other  is  fixed. 
The  foot  appears  shortened  in  front,  where  the  lower  end  of  the  tibia 
projects  prominently  and  rests  upon  the  scaphoid  and  cuneiform  bones, 
and  the  extensor  tendons  may  be  felt  as  tense  cords.  The  heel  is  length- 
ened. As  a  result  of  fracture  of  the  ankle  by  eversion,  partial  and  even 
complete  backward  dislocations  are  not  infrc'f|uent,  l)Ut  pure  dislocations 
of  this  kind  are  rare.  Forward  dislocation  is  still  more  rare.  The 
mode  of  production  and  the  deformity  of  the  foot  are  the  reverse  of  the 
last  variety. 

Two  forms  of  dislocation  inward  are  observed.  In  one  (lie  foot  is 
much  inverted  so  that  the  astragalus  can  be  felt  and  seen  as  a  promi- 
nence below  the  outer  malleolus.  In  the  other  there  is  less  or  no 
inversion,  but  the  foot  is  much  adducted  so  that  the  toes  may  even  point 


470 


THE  LOWER  EXTREMITY. 


directly  inward.  The  latter  form  may  be  secondary  to  a  backward 
dislocation. 

The  so-called  outward  dislocations  represent  the  deformity  in  cases 
of  Pott's  fracture  (fracture  by  eversion). 

Fractures  of  the  bones  of  the  leg  just  above  the  ankle  are  pro- 
duced by  eversion  or  inversion  of  the  foot,  aided  somewhat  by  the 
weight  of  the  body.  Both  eversion  and  inversion  produce  fractures 
which  are  very  similar.  In  reference  to  these  fractures  it  should  be 
remembered  that  the  tibia  and  fibula  are  very  strongly  bound  together 
at  their  inferior  articulation,  and  that  this  point  serves  as  the  fulcrum 
of  a  lever,  of  which  the  external  malleolus  represents  the  short  arm 
and  the  fibula  above  the  joint  the  long  arm. 

Fig.  115. 


Diagram  of  fracture  by  eversion  of  the  ankle,  showinglthe  fractures  of  the  two  bones. 

In  fractures  due  to  forcible  eversion  (Pott's  fracture)  (Fig.  1 1 5), 
the  strain  first  comes  on  the  internal  lateral  ligament^ivhich  may  tear  but, 
owing  to  its  strength,  usually  tears  off  the  internal  malleolus  at  its  base. 
This  allows  the  further  eversion  of  the  foot  and  the  astragalus  then  presses 
the  external  naalleolus  outward.  This  is  resisted  by  the  strong  liga- 
ments of  the  inferior  tibiofibular  joint,  which  suffer  violence  in  the 
shape  of  partial  rupture  or  strain,  but  usually  hold  the  bones  together, 
so  that  the  strain  comes  upon  the  long  arm  of  the  lever,  the  shaft  of 
the  fibula,  which  breaks  a  little  (1-3  inches)  above  the  malleolus.  The 
upper  end  of  the  lower  fragment  of  the  fibula  is  displaced  toward  the 


FRACTURE  BY  INVERSION. 


471 


tibia.  The  foot  is  displaced  outward  and  often  somewhat  backward 
and  everted,  the  inner  malleohis  is  very  prominent  and  may  can-^e  the 
laceration  of  the  taut  overlying  skin.  The  characteristic  features  are 
(1)  lateral  mobility,  due  to  some  spreading  of  the  tibiofii)ular  joint 
and  to  the  fracture  of  the  internal  malleolus  and  the  fil)ula  above  its 
malleolus  and  (2)  tlivcc  points  of  fcnderncs.s — (r/)  in  front  of  the  tibio- 
fibular joint  in  the  groove  between  the  tibia  and  the  external  malleolus, 
(h)  over  the  base  or  apex  of  the  internal  malleolus  and  [c)  over  the 
fibula  just  above  the  malleolus,  or  1-2  inches  higher. 

Fig.  IIG. 


Diagram  of  fracture  by  inversion  of  tlie  ankle.  Fracture  of  the  fibula  only  is  represented  and  at 
two  levels.  The  dotted  lines  show  a  fracture  of  the  fibula  some  distance  above  the  malleolus,  the  con- 
tinuous lines  a  fracture  at  the  base  of  the  niallculus. 


In  fractures  due  to  forcible  inversion  (Fig,  1 1(5)  the  external  lat- 
eral ligament  first  feels  the  strain.  If  the  ligament  gives  way  simply  d 
sprain  may  result,  unless  the  action  of  the  force  continues.  If  the  liga- 
ment holds,  and  it  commonly  does,  it  pulls  the  tiji  of  the  external  malle- 
olus inward,  which  forces  the  long  arm  of  the  fibular  lever  outward, 
until  it  breaks  close  al)()ve  tlie  malleolus,  or  still  higher.  The  force 
continuing  inverts  the  foot  still  further  and  theastragalus  presses  against 
the  internal  malleolus  and  breaks  off  the  latter  or  a  longer  portion  of 
the  lower  end  of  the  tibia.  The  lateral  mohilitif  (ouJ  the  three  p()i)it,'<  of 
tendcrnes.s  are  present  in  this  form,  but  perhaps  not  so  markeillv.  In 
this  form   the   injury  may  stop   short  with  fracture  of  the   fibula,  no 


472  THE  LOWER  EXTREMITY. 

injuiy  of  the  internal  malleolus  or  internal  ligament  resulting.  In 
fractures  by  inversion  the  upper  end  of  the  lower  fragment  of  the 
fibula  is  displaced  outward,  unless  it  is  held  by  the  untorn  periosteum. 
To  determine  the  presence  and  the  point  of  fracture  of  the  fibula  an 
excellent  way  is  to  press  on  the  tip  of  the  malleolus,  the  short  arm  of 
the  lever,  which  causes  a  false  point  of  motion,  or  at  least  a  point  of 
tenderness,  to  appear  at  the  upper  end  of  the  lower  fragment. 

Owing  to  the  frequency  of  these  two  classes  of  fractures  and  the  dis- 
ability following  improper  treatment  they  should  be  carefully  reduced 
and  treated.  It  is  especially  important  to  correct  the  lateral  displace- 
ment and  the  eversion,  otherwise  the  gait  is  painful  and  im- 
perfect. 

The  lower  epiphysis  of  the  tibia  is  more  often  separated  than  the  upper. 
The  fibula  is  usually  broken  at  the  same  time  at  a  higher  level  though 
its  epiphysis,  which  reaches  to  the  level  of  the  tibial  articular  surface, 
is  sometimes  separated  in  place  of  a  fracture  of  the  shaft.  The  lower 
epiphysis  of  the  tibia  includes  the  malleolus  and  the  articular  surface, 
and  unites  in  the  nineteenth  year;  the  loirer  epiphysis  of  the  fibula  includes 
the  outer  malleolus  to  the  limit  of  its  articular  facet  and  unites  about 
the  twenty-first  year.  Both  epiphyseal  lines  are  horizontal  and  are  in 
contact  with  the  synovial  membrane,  which  extends  up  between  the 
two  bones. 

Excision  of  the  ankle  is  rarely  done  for  injury  and  not  often  for 
tubercular  disease.  Symes'  or  Pirigoff's  amputation  often  gives  a 
better  result.  Bilateral  incisions  are  usually  made  over  the  malleoli ; 
curving  forward  over  the  foot  in  such  a  way  as  to  lie  between  the  ten- 
dons in  front  and  those  behind  the  malleoli.  Konig  chisels  away  the 
attachments  of  the  lateral  ligaments  to  the  malleoli  to  spare  the  liga- 
ments. Lauenstein  uses  a  single  long  external  incision,  Kocher  a 
transverse  external  incision,  and  both  of  the  latter  then  retract  the 
peroneal  tendons  backward,  divide  the  external  lateral  ligaments  and 
fully  supinate  (invert)  the  foot,  so  as  to  expose  both  articular  surfaces. 

THE  FOOT. 

Landmarks  and  Surface  Markings. — Along  the  outer  border  of 
the  foot  nearly  the  entire  outer  surface  of  the  calcaneum  is  subcuta- 
neous, and  we  can  feel  its  peroneal  tubercle,  less  than  an  inch  below  the 
malleolus.  The  short  peroneal  tendon  is  above,  the  long  one  below  it. 
The  base  of  the  fifth  metatarsal  bone  is  the  most  prominent  landmark 
on  this  border  and  can  be  felt  under  all  conditions  of  swelling,  etc. 
The  cuboid  extends  for  an  inch  or  so  behind  it,  and  it  is  about  2| 
inches  in  front  of  the  external  malleolus.  Along  the  inner  border  of 
the  foot  we  can  feel  the  tuberosity  of  the  calcaneum  ;  the  sustentaculum 
tali,  1  inch  below  the  internal  malleolus  ;  the  tuberosity  of  the  scaphoid, 
about  an  inch  in  front  of  and  a  little  below  the  internal  malleolus  ;  the 
base  and  head  of  the  first  metatarsal  bone,  and  the  sesamoid  bones  on 
the  plantar  surface  of  the  latter.     The  tuberosity  of  the  scaphoid  is  the 


THE  PLANTAR  ARTERIES  AND  ARCHES.  473 

best  landmark  on  the  inner  border  and  can  be  felt  even  when  the  foot 
is  much  swollen.  In  such  conditions  the  head  of  the  metatarsal  bone 
is  not  plainly  palpable,  hence  it  is  well  to  know  that  the  jimt  tarsomrt- 
atarsal  articulation  is  3  cm.  in  front  of  the  tuberosity  of  the  scaphoid 
and  2  cm.  in  front  of  the  inner  end  of  a  line  drawn  transversely  across 
the  foot  from  the  base  of  the  fifth  metatarsal  Ixtne. 

Topography. — The  mediotarsal  joint,  /.  e.,  the  joint  between  the 
astragalus  and  calcaneum  posteriorly  and  the  scaphoid  and  cuboid 
anteriorly,  commences  internally  just  beiiind  the  scaphoid  tuberosity 
and  externally  midway  between  the  tip  of  the  external  malleolus  and 
the  base  of  the  fifth  metatarsal  bone.  The  joint  line  is  transverse  with 
a  slight  sinuosity,  convex  forward  internally  and  concave  forward  ex- 
ternally. The  position  of  the  first  tarsometatarsal  joint  has  already 
been  indicated,  that  of  the  fifth  lies  just  behind  the  prominent  base  of 
the  fifth  metatarsal  bone.  The  tarsometatarsal  Joint  line,  between  these 
two  ends,  is  interrupted  by  the  mortising  of  the  second  metatarsal  bone 
between  the  internal  and  external  cuneiform.  The  line  of  its  articu- 
lation with  the  middle  cuneiform  is  1  cm.  behind  that  of  the  first 
joint.  The  metatarsopJialanejeal  articulations  are  about  one  inch  behind 
the  webs  between  the  corresponding  toes,  the  proximal  and  part  of  the 
middle  phalanges  being  buried  in  the  web.  The  gap  between  the 
internal  malleolus  and  the  tuberosity  of  the  scaphoid  is  filled  by 
the  inferior  calcaneoscaphoid  ligament  and  the  tendon  of  the  tibialis 
posticus  beneath  it.    . 

On  the  outer  part  of  the  dorsum  of  the  foot  the  fleshy  mass  of  the 
extensor  brevis  digitorum  can  be  felt  beneath  the  tendons  of  the  exten- 
sor longus  digitorum,  where  it  can  be  seen  when  in  action.  It  fills  the 
gap  between  the  front  of  the  astragalus  and  the  calcaneum.  The 
course  of  the  dorsalis  pedis  artery  has  been  given  above  (see  p.  46(5); 
it  is  crossed  by  the  inner  tendon  of  the  extensor  brevis  muscle. 

The  plantar  arteries  start  at  the  bifurcation  of  the  posterior  tibial, 
midway  between  the  inner  malleolus  and  the  inner  border  of  the  heel. 
Thence  the  smaller  branch,  the  internal  plantar,  follows  a  line  to  the 
middle  of  the  plantar  surface  of  the  great  toe.  The  course  of  the  e.rter- 
nal plantar  is  obliquely  across  the  sole  to  a  point  a  little  internal  to  the 
base  of  the  fifth  metatarsal  bone,  and  thence  obliquely  inward  across 
the  bases  of  the  metatarsal  bones,  covered  by  the  interossci,  to  the  iiack 
of  the  first  interosseous  space,  where  its  arch  is  completed  by  anasto- 
mosing with  the  communicating  branch  of  the  dorsalis  pedis.  By 
means  of  this  arch  the  anterior  and  posterior  tibial  arteries  anastomose. 
In  /rounds  of  the  plantar  arch,  which  are  serious  on  account  of  its 
depth  beneath  many  important  structures,  the  ligature  of  i)oth  tibial 
vessels,  at  or  just  above  the  ankle,  would  not  arrest  the  hemorrhage 
without  fail,  for  the  peroneal  artery  would  bring  blood  to  the  arch 
through  (1)  the  anastomosis  of  the  anterior  peroneal  with  the  external 
malleolar  branch  of  the  anterior  tibial  and  the  tarsal  branch  of  the 
dorsalis  pedis,  and  (2)  the  anastomosis  of  its  terminal  branch  with  the 
internal  calcaneal  branch  of  the   external  plantar  artery.      In   fact. 


474  THE  LOWER  EXTREMITY. 

however,  elevation  and  pressure  will  check  most  hemorrhages  of  the 
foot. 

The  skin  of  the  dorsum  and  inner  aspect  of  the  foot  is  thin  and 
movable,  that  of  the  sole  is  dense  and  thick  where  it  normally  comes 
in  contact  with  the  ground,  i.  e.,  under  the  heel,  the  outer  border,  and 
the  distal  ends  of  the  metatarsal  bones.  The  skin  on  the  dorsum  is 
readily  excoriated.  The  skin  of  the  foot  becomes  thick  and  callous 
wherever  it  is  exposed  to  undue  pressure.  Beneath  the  abnormal 
thickenings  hursce  may  develop. 

The  subcutaneous  tissue  on  the  dorsum  is  lax  and  abundant  so 
that  great  swelling  occurs  from  inflammation,  and  oedema  and  general 
dropsy  are  often  first  evident  here.  This  tissue  is  very  thick  and  dense  on 
the  sole,  connecting  the  skin  closely  with  the  fascia  and  enclosing  the 
fat  in  little  spaces,  as  in  the  palm  and  the  scalp.  Hence  the  skin  of  the 
sole  does  not  gape  on  being  incised,  so  that  exploratory  incisions  must 
be  longer  than  otherwise  and  strongly  retracted,  to  expose  foreign 
bodies,  etc.  It  is  most  abundant  on  the  sole,  where  the  pressure  is 
greatest,  and  in  those  who  walk  most,  and  may  even  reach  2  cm.  in 
thickness  beneath  the  heel,  so  that  it  forms  a  veritable  cushion  that 
must  diminish  the  effect  of  contusions  and  falls.  Owing  to  its  density 
inflammation  in  it  extends  with  difficulty  and  can  produce  little  swelling 
but  much  jmin,  especially  as  the  skin  of  the  sole  is  well  supplied  with 
nerves  and  is  very  sensitive,  much  more  so  than  that  of  the  dorsum. 

In  the  subcutaneous  tissue  on  the  dorsum  many  superficial  veins  are 
visible.  They  form  an  arch,  concave  toward  the  ankle,  from  the  ends 
or  sides  of  which  the  internal  and  external  saphenous  veins  arise.  In 
varicose  veins  of  the  leg  these  veins  of  the  dorsum  are  often  involved. 
The  internal  and  external  saphenous  and  the  musculocutaneous  nerves 
are  in  the  same  subcutaneous  layer.  "  Perforating  ulcer,"  a  peculiar 
affection,  occurs  generally  at  the  points  of  pressure,  and  is  often  attrib- 
uted to  trophic  disturbances  in  certain  nerve  lesions,  like  locomotor 
ataxia,  etc.  It  appears  usually  as  a  sinus  leading  to  bone,  into  a  joint, 
or  through  to  the  dorsum,  and  often  heals  with  rest. 

The  fascia  of  the  dorsum  consists  of  two  layers  ;  the  more  super- 
ficial one  is  continuous  with  the  annular  ligaments  and  covers  the  long 
tendons ;  the  deeper  forms  a  sheath  for  the  extensor  brevis  muscle 
and  covers  the  dorsalis  pedis  artery.  They  are  thin  and  of  no  surgi- 
cal importance.  On  the  contrary  the  deep  fascia  of  the  sole  or  plantar 
fascia  is  very  important  and,  like  the  palmar  fascia,  consists  of  three 
parts,  a  dense  strong  central  portion  and  two  thinner  lateral  portions. 
The  outer  portion  is  however  very  strong  and  forms  a  firm  band  be- 
tween the  calcaneum  and  the  fifth  metatarsal  bone.  The  central  por- 
tion is  stretched  like  a  bow-string  between  the  two  ends  of  the  longi- 
tudinal arch  of  the  foot,  the  inner  tuberosity  of  the  calcaneum  and  the 
heads  of  the  metatarsal  bones,  where  it  divides  into  slips  for  the  toes 
similar  to  those  for  the  fingers  in  the  hand.  Hence  the  plantar  fascia, 
especially  its  central  portion,  is  an  important  factor  in  maintaining  the 
longitudinal  arch  of  the  foot,  the  sinking  of  which,  in  flat  foot,  necessi- 


LYMPHATICS  OF  THE  SOLE.  475 

tales  a  marked  yielding  of  this  fascia.  Tfi/iprs  cavn«,  in  which  the 
arch  is  much  raised,  (hpauh  largely  or  entirely  upon  a  contraction  of 
tins  fascia.  In  this  condition  and  in  talipes  varus,  in  which  this  fapcia 
is  often  contracted  and  the  arch  correspondingly  raised,  the  fascia  is 
divided  suhcutancousli/  hi/  a  frnotomr  to  cure  the  deformity.  This  divi- 
sion is  best  made  iihont  one  inch  in  front  of  its  posterior  attachment,  in 
its  narrowest  part,  where  the  knife,  entered  from  the  inner  side,  is  be- 
hind the  external  plantar  artery.  Tliis  fascia  bears  the  same  relation  to 
inflammation  and  abscess  as  the  palmar  fascia  in  the  hand.  Similarly 
tii'o  inter nmscidar  septa  pass  from  its  deep  surface,  where  it  joins  the 
lateral  portions,  to  the  plantar  aspect  of  the  bones  and  the  interosseous 
fascia.  TJiree  muscular  compartments  are  thus  formed,  of  which  the 
central  one  is  the  larger  and  deeper  and  contains  the  majority  of  the 
muscles  and  tendons  and  the  plantar  vessels  and  nerves.  These  inter- 
muscular septa  are  too  feeble  to  affect  the  course  of  a  deep  plantar 
abscess  to  any  great  extent. 

The  posterior  tibial  nerve  bifurcates  a  little  above  the  artery,  and 
the  internal  plantar  nerve,  unlike  the  corresponding  artery,  is  the 
larger  of  the  two.  //(  its  didribution  the  internal  plantar  nerve  cor- 
responds closely  with  that  of  the  median  in  the  hand,  the  external 
plantar  with  the  ulnar. 

The  bursa  in  the  subcutaneous  tissue  over  the  first  metatarso-pha- 
langeal  joint,  when  enlarged,  constitutes  a  bunion.  This  is  usually  as- 
sociated with  a  deformity  of  the  great  toe  (hallux  valfju^),  generally 
due  to  improperly  shaped  or  too  short  shoes,  which  force  the  great  toe 
outward  and  render  its  metatarso-phalangeal  joint  very  prominent  in- 
ternally. The  overlying  skin  becomes  thickened  and  indurated  and  the 
bursa,  pressed  between  this  thickening  and  the  projecting  bone,  becomes 
injlaiiied.  If  it  suppurates  it  often  opens  both  superficially  and  into 
the  joint.  The  latter  then  becomes  disorganized  and  requires  resec- 
tion. In  this  operation  it  must  be  remembered  that  the  outwardly 
displaced  extensor  tendon  of  the  toe  and  the  inner  })art  of  the  fibrous 
capsule  of  the  joint  have  probably  both  become  contracted  and  short- 
ened. Holden  describes  the  frequent  occurrence  of  a  large  irregular 
bursa  between  the  tendons  of  the  extensor  longus  digitorum  and  the 
underlying  prominent  end  of  the  astragalus,  which  sometimes  com- 
municates with  the  mediotarsal  joint.  Burstr  may  develoji  almost 
anywhere  from  pra<sure,  as  beneath  the  points  on  which  the  foot  rests 
in  the  various  forms  of  clul)  foot. 

The  numerous  fine  lymphatics  of  the  sole  pass  to  the  borders  of  the 
foot,  especially  the  inner  border,  and  to  tiie  di)rsum,  wiiere  the  main 
lymph  vessels  are  found,  j)articularly  on  its  inner  side.  Thence  they 
run  along  the  inner  side  of  the  leg  with  the  internal  saphenous  vein, 
and  pa^s  mostly  to  the  inf/uinal  nodes.  Some  run  up  the  outer  side  of  the 
leg,  or  with  the  short  saphenous  vein,  but  most  of  the  former  cross 
over  the  popliteal  s])ace,  or  the  front  of  the  leg,  to  join  the  inner  ves- 
sels, so  that  ouly  a  feir  enter  the  popliteal  nodes.  Hence  in  iufiamma- 
tion  on  the  dorsum  and  inner  border  of  the  foot  lympiiatic  enlarge- 


476  THE  LOWER  EXTREMITY. 

ment  will  involve  the  inguinal  nodes,  while  inflammation  on  the  outer 
border  may  affect  either  the  inguinal  or  popliteal  nodes.  Lymphan- 
gitis most  often  follows  lesions  of  the  dorsum  and  inner  border. 

The  foot  is  arched  in  two  directions,  longitudinally  and  transversely. 
Th&se  arches  are  due  to  the  shape  of  the  bones  and  are  maintained  by 
ligaments  and,  to  a  less  extent,  by  the  tendons  and  short  muscles  of 
the  sole. 

The  longitudinal  arch,  the  more  important  of  the  two,  consists  of 
two  piers  on  the  ends  of  which  the  foot  rests,  /.  e.,  the  heel  and  the 
heads  of  the  metatarsal  bones.  In  addition  the  foot  is  supported  or 
buttressed  by  its  outer  border.  The  middle  of  the  inner  border  and  the 
inner  part  of  the  sole  is  raised  from  the  ground  by  the  inner  and  more 
curved  portion  of  the  arch,  which  is  thus  known  as  the  instep.  On 
account  of  this  difference,  of  the  two  borders  the  arch  is  divided,  into  two 
jxirts  having  a  common  posterior  pillar,  the  calcaneum  and  the  hind 
part  of  the  astragalus.  The  anterior  pillar  of  the  outer  and  flatter 
arch  is  formed  by  the  cuboid  and  the  two  outer  metatarsals ;  the 
anterior  pillar  of  the  inner  and  more  curved  arch  is  formed  by 
the  scaphoid,  cuneiform  and  three  inner  metatarsals.  The  outer 
arch  forms  a  buttress  to  steady  the  more  elastic  inner  arch.  The 
anterior  pillars  composed  of  a  number  of  small  bones  and  their  joints 
are  very  dastie  and  springy,  giving  the  elasticity  to  the  gait.  The 
posterior  arch,  consisting  of  only  one  joint  and  two  bones,  astragalus 
and  calcaneum,  is  solid  in  order  to  support  the  greater  part  of  the 
weight  of  the  body,  and  inelastic  to  give  a  firm  attachment  to  the  calf 
muscles.  The  difference  in  the  two  arches  is  seen  in  jumping  from  a 
height.  When  we  alight  on  the  heels  the  jar  is  felt  throughout  the 
body,  but  when  we  alight  on  the  ball  of  the  foot  the  elasticity  of  the 
anterior  pillar  of  the  arch  absorbs,  so  to  speak,  all  the  jar.  The  astra- 
galus, or  more  especially  its  head,  serves  as  the  keystone  of  the  arch, 
but,  unlike  keystones  in  ordinary  arches,  it  is  not  wedge-shaped,  it  is 
mobile  and  it  only  imperfectly  supports  and  receives  support  from  the 
two  pillars. 

The  transverse  arch  is  most  marked  near  the  tarsometatarsal  joints 
and  is  due  to  the  wedge  shape  of  the  bones.  //  protects  the  vessels  and 
soft  parts  of  the  sole  and,  by  its  yielding  in  walking,  etc.,  gives  elas- 
ticity and  spring  to  the  foot. 

Both  of  the  arches  are  maintained  by  ligaments  and  tendons.  The 
transverse  arch  is  maintained  by  the  transversely  directed  dorsal,  plantar 
and  interosseous  ligaments,  and  by  the  obliquely  directed  peroneus 
longus  tendon  and,  to  some  extent,  the  expansion  of  the  tibialis  posticus 
tendon.  When  the  transverse  arch  is  properly  maintained  the  anterior 
pillar  of  the  longitudinal  arch  rests  upon  the  heads  of  the  first  and 
fifth  metatarsal  bones  only.  If  the  transverse  arch  yields  the  heads  of 
the  intervening  metatarsal  bones  receive  undue  pressure  and  callosities 
develop  over  them.  The  longitudinal  arch  is  maintained  principally  by 
the  inferior  ligaments  of  the  mediotarsal  joint,  the  long  and  short 
plantar  and  the  inferior  calcaneo-scaphoid  ligaments.     The  former  are 


CLUB-FOOT.  477 

the  main  supi)()rt  of  the  outer,  firmer  and  less  elastic  part  of  the  arch  ; 
the  latter  is  known  as  the  "  spriiu/  H<j(iiarni"  as  it  is  the  princij)al 
ligament  that  supports  the  inner  and  more  springy  ])art  of  the  areh. 
It  helps  to  support  the  head  of  the  astraf/alus,  part  of  which  rests  directly 
upon  it.  It  in  turn  is  KuppoiinJ  hi/  the  tlbidHs  jjosticits  feiaJon,  which 
runs  in  a  groove  on  its  under  surface  and  comes  into  action  when  the 
heel  is  raised  and  the  weight  is  thrown  onto  the  instep,  and  therefore 
when  the  most  strain  comes  on  this  ligament  in  supporting  the  head  of 
the  astragalus  and  the  mediotarsal  joint.  The  tibialis  anticus  is  said 
to  support  the  keystone,  but  as  no  keystone  can  be  supported,  but  only 
weakened,  by  traction  from  above,  it  can  only  support  it  by  reason  of 
the  fact  that  the  constituents  of  the  arch  are  connected  and  supported 
by  ligaments. 

Fkj.  117. 


Flat-foot.  Normal  foot. 


Club-foot. —  The  longitudinal  arch  sometimes  yields  and  faffrns  out. 
This  gives  rise  to  one  variety  of  club-foot  known  as  "flat-foot,"  in 
which  the  foot  is  abducted  and  pronated  (everted),  the  sole  becomes  flat 
and  the  patient  walks  mainly  on  the  inner  side  of  the  foot.  Some  ab- 
duction of  the  foot  is  necessarily  anatomically  associated  with  raising 
of  the  outer  border,  or  pronation,  for  the  pronating  peronci  are  also 
abductors.  The  imj)ressiou  of  the  Avet  sole  on  a  sheet  of  paper  shows 
no  deep  concavity  along  the  inner  border,  as  normally,  but  rather  a 
convexity.  (See  Fig.  117.)  It  occurs  particularly  in  tho.«;e  who 
stand  a  great  deal  and  especially  in  adoleseents  wiio  are  below  })ar, 
who  have  grown  rapidly  and  in  whom  the  muscles  and  ligaments 
are  relaxed  and  more  ready  to  yield  to  long  continued  pressure. 
The  inferior  calcdneo-scaphoid  ligament  suffers  most  and  by  its  yielding 
allows  the  head  of  the  astragalus  to  be  jiressed  downward,  forward 
and  inward,  so  that  tiie  latter,  together  with  the  depressed  sustenta- 
culum tali  and  the  sca})hoid  tuberosity,  form  prominences  on  the 
inner  border  of  the  foot,  which  may  rest  on  the  ground.  The  plantar 
and  deltoid  ligaments  and  the  plantar  fascia  also  yield,  and  in  time 
the  deformity  may  be  rendered  permanent  by  alterations  in  the  shajie 
of  the  bones,  by  contraction  of  the  ligaments  that  are  relaxeil  and  by 
shortening  of  the  peronei   muscles,  which   are  rcla.xed   by  the  abduc- 


478  THE  LOWER  EXTREMITY. 

tion  and  eversion  of  the  foot.  In  this  acquired  deformity,  occurring 
in  the  developed  foot  of  adolescents  or  adults,  the  affected  tarsal  bones 
and  articulations  suifer  abnormal  pressure,  which  often  causes  severe 
pain.  The  latter  gives  rise  to  the  term  ^^  painful  flat-foot,^^  to  distin- 
guish it  from  a  similar  deformity  without  pain,  which  may  be 
congenital.  The  acquired  deformity  is  also  known  as  acquired  talipes 
valgus,  the  congenital  as  congenital  talipes  valgus.  The  latter  is  usually 
associated  with  some  talipes  calcaneus.  The  normal  foot  is  not  flat  at 
birth. 

Talipes  is  a  term  applied  to  all  forms  of  club-foot,  of  which  there  are 
four  primary  varieties  which  may  be  variously  combined  with  one 
another.  In  talipes  equinus  the  heel  is  drawn  up  by  the  contraction  of 
the  calf  muscles  so  that  the  patient  ivalks  on  the  bases  of  the  toes.  The 
arch  of  the  foot  is  often  exaggerated.  Talipes  equinus  is  rarely  con- 
genital and  results  from  infantile  paralysis  of  the  extensor  tendons  and 
other  paralytic  lesions,  as  well  as  from  the  long  continued  extended  posi- 
tion of  the  foot,  due  to  faulty  splints  or  the  weight  of  the  bed  clothes 
in  cases  of  long  illness,  etc. 

The  opposite  condition,  talipes  calcaneus,  is  characterized  by  dorsal 
flexion  and  is  due  to  contraction  of  the  anterior  muscles,  usually  asso- 
ciated with  infantile  paralysis  of  the  posterior  groups.  The  patient 
walks  on  the  heel  with  the  foot  drawn  up.  It  is  rarely  congenital 
and  often  combined  with  talipes  valgus  and  pes  cavus. 

In  talipes  varus  the  foot  is  inverted,  and  hence  also  adducted,  for  the 
same  muscles  produce  both  actions.  It  rarely  occurs  without  some 
talipes  equinus,  and  talipes  equinovarus  or  congenital  club-foot  is  the 
commonest  form  of  club-foot.  It  usually  originates  in  an  arrest  of  the 
fatal  development  of  the  feet,  resulting  in  the  delayed  rotation  of  the 
feet  and  legs,  so  that  the  equinovarus  position  of  the  feet  that  is 
normal  in  early  foetal  life  persists.  A  similar  deformity  may  result 
from  infantile  paralysis.  The  deformity  is  a  kind  of  dislocation  in- 
ward of  the  fore  part  of  the  foot  at  the  mediotarsal  joint,  and  consists 
of  elevation  of  the  heel,  inversion  and  adduction  of  the  foot  and  increase 
of  its  longitudinal  arch,  associated  with  contracture  of  the  plantar  fascia. 
Hence  the  patient  walks  on  the  outside  or,  in  extreme  cases,  even  on  the 
dorsum  of  the  foot.  The  toes  point  inward  so  that  one  foot  is  lifted 
over  the  other  in  walking.  The  os  calcis  becomes  more  vertical  than 
horizontal ;  the  head  and  the  elongated  neck  of  the  astragalus  are 
rotated  downward  and  twisted  inward  ;  and  the  scaphoid,  with  the 
three  cuneiform  and  the  three  inner  metatarsals,  are  displaced  inward, 
upward  and  backward.  The  tarsal  bones  become  much  misshapen. 
The  neck  of  the  astragalus  is  deflected  inward  from  the  axis  of  its  body 
at  an  angle  of  10°  in  the  adult,  25°  at  birth  and  50°  in  talipes  equi- 
novarus. The  ligaments  are  contracted  on  the  concave  inner  side  and 
stretched  on  the  other  side.  The  peroneus  longus  tendon  may  slip  in 
front  of  the  external  malleolus.  In  most  forms  of  club-foot  the  con- 
tracted muscles  require  tenotomy,  also  the  plantar  fascia  when  that  is 
contracted. 


DISLOCATION^  OF  THE  ASTRAGALUS.  479 

The  chief  joints  of  tlie  foot  are  the  calcaneoastragaloid,  the  medio- 
tarsal  and  the  tarsometatarsal. 

The  principal  lif/tinieid  of  tlie  caleaiieoastragaloid  j(nnt.s,  from  a 
surgical  standpoint,  is  the  massive  interosscoiui  Hf/aiiwut  in  the  sinus 
pedis.  The  lateral  ligaments  of  the  ankle,  tlie  surrounding  tendons, 
the  various  calcaneoastragaloid  and  the  external  calcaiU'osc-aj)lMiid 
ligaments  help  to  hold  the  bones  together.  Tiiis  is  a  double  joint,  the 
posterior  having  a  separate  synovial  sac,  the  anterior  a  sac  in  common 
with  the  astragaloscaphoid  joint.  The  moveinents  of  ab-  and  adduc- 
tion and  some  pro-  and  supination  are  allowed.  This  joint  is  of  prac- 
tical interest  in  subastragaloid  amputation,  subastragaloid  dislocation 
and  dislocation  of  the  astragalus. 

Subastragaloid  dislocation  involves  the  astragaloscaphoid  and 
calcaneoastragaloid  joints.  The  jiosition  and  relation  of  the  astra- 
galus with  the  tibia  and  fibula  and  the  movements  in  the  ankle  joint 
remain  normal.  In  tliese  dislocations  the  foot  /.s  disphiced  either 
(1)  inward,  or  rather  inward  and  backward,  or  (2)  outward,  very 
rarely  (•!)  backward  or  (4)  forward.  In  the  dislocation  inward  and 
backward  the  dorsum  is  shortened,  the  heel  lengthened,  the  foot  ad- 
ducted  and  supinated,  the  external  malleolus  and  the  head  of  the  as- 
tragalus are  very  prominent  on  the  outer  side  of  the  dorsum,  and  the 
internal  malleolus  is  deeply  buried.  The  deformity  resembles  talipes 
varus.  The  cause  is  often  forcible  inversion  and  adduction  of  the  f(X>t. 
In  the  outward  dislocation  either  the  outward  displacement  may  be 
combined  irith  marked  abduefion  of  the  toes,  when  the  foot  turns  on  the 
posterior  calcaneoscaphoid  joint  if  the  bones  have  not  separated  there, 
or  the  foot  may  be  displaced  bodily  outward.  Hence  the  dislocation  may 
be  incomplete  as  regards  the  posterior  calcaneoastragaloid  joint. 
AVhen  the  foot  is  abducted  there  is  more  or  less  eversion  and  the  head 
of  the  astragalus  is  very  prominent  on  the  inner  side.  In  the  form 
with  simple  outward  displacement  the  inner  malleolus  is  very  promi- 
nent and  approaches  the  level  of  the  sole.  The  head  of  tlie  astragalus 
projects  below  and  in  front  of  it,  while  the  outer  malleolus  is 
buried  in  the  depression  above  the  prominence  of  the  outer  surface  of 
the  calcaneum  and  cuboid.     The  subastragaloid  dislocations  are  often 

coinpolliidcd. 

Dislocation  of  the  astragalus  is  a  combination  of  the  subastraga- 
loid dislocation  and  that  of  the  ankle,  and  is  much  more  frequent  than 
either  of  them.  It  is  often  compound  and  either  or  both  mal/eod  may 
be  fractured.  The  astragalus  may  be  displaced  antero-jx)steriorly 
or  laterally.  Dislocation  outward  and  forward  is  the  commonest 
form,  inward  and  forward  the  next,  simply  forward  or  i)a('kward  rare, 
and  inward  is  almost  unknown.  In  the  dislocation  outward  and  forward 
the  head  of  the  astragalus  rests  on  the  cuboid  and  I'xternal  cuneiform, 
and  is  freelv'  movable.  TJie  foot  is  adducted,  inverted  and  usually 
displaced  inward  so  that  the  internal  malleolus  is  buric<l,  the  external 
is  prominent.  In  the  inward  and  forward  dislocation  the  head  of  the 
astragalus  projects   below  and    in  front  of  the   inner  malleolus  and  is 


480  THE  LOWER  EXTREMITY. 

much  depressed,  as  if  rotated  on  a  transverse  axis.      The  foot  is  usually 
everted  and  abducted,  but  sometimes  simply  displaced  outward. 

The  malleoli  are  brought  nearer  the  sole  in  almost  all  cases  of  dis- 
location of  the  astragalus.  In  Q.dd\\Aontheadragaluii,  while  remaining 
within  the  tibiofibular  mortise,  may  rotate  on  its  autero-posterior  axis, 
sometimes  on  its  vertical  axis.  Dislocation  of  one  or  more  of  the  other 
tarsal  and  of  the  metatarsal  bones  occasionally  occurs,  the  most  frequent 
being  dislocations  of  the  scaphoid,  the  inner  cuneiform  or  the  first 
metatarsal. 

The  mediotarsal  joint,  composed  of  the  astragaloscaphoid  and  cal- 
caneocuboid joints  is  the  most  movable  of  the  tarsal  joints  and  permits 
ab-  and  adduction,  pro-  and  supination,  and  flexion  and  extension 
of  the  fore  part  of  the  foot  on  the  back  part.  In  these  movements 
flexion  is  combined  with  adduction  and  supination  of  the  foot,  extension 
with  abduction  and  pronation  of  the  foot,  owing  to  the  obliquity  of  the 
axis  of  this  joint,  from  within  outward  and  somewhat  backward  and 
downward.  This  combination  is  seen  in  talipes  varus  and  valgus  in 
which,  as  well  as  in  pes  cavus  and  pes  planus,  the  principal  displace- 
ment occurs  in  the  mediotarsal  joint.  In  studying  the  arches  of  the 
foot  we  have  seen  that  tJte  inferior  lir/aments  of  this  joint  (the  inferior 
calcaneoscaphoid  and  the  plantar  ligaments)  are  the  jirincipal  support 
of  the  longitudinal  arch. 

Exclusive  of  that  of  the  ankle  there  are  six  synovial  membranes 
among  the  joints  of  the  tarsus  and  sometimes  seven,  if  there  is  a  sepa- 
rate sac  between  the  cuboid  and  external  cuneiform.  The  most  exten- 
sive is  that  between  the  scaphoid  and  the  three  cuneiform  bones,  which 
extends  forward  between  the  latter  to  the  second  and  third  tarso- 
metatarsal joints  and  the  joints  between  the  second  and  third  and  third 
and  fourth  metatarsal  bones.  Hence  disease  of  the  bones  in  relation 
to  this  joint  would  be  most  likely  to  extend,  while  that  of  the  bones 
near  the  posterior  calcaneoscaphoid  joint  would  be  least  likely  to  do  so. 

Through  each  of  the  three  principal  joints  of  the  foot  that  we  have 
named,  amputation  may  be  practiced.  In  subastragaloid  amputation  the 
astragalus  is  disarticulated  from  the  calcaneum  and  the  scaphoid  and 
two  synovial  sacs  are  opened.  The  extremity  rests  on  the  astragalus 
and  the  operation  gives  a  good  result.  In  Chopart's  amputation  through 
the  mediotarsal  joint  two  synovial  sacs  are  opened.  Subsequently, 
from  contraction  of  some  muscles  or  loss  of  the  point  of  attach- 
ment of  their  antagonists  the  heel  may  be  drawn  up  by  the  calf 
muscles  so  that  the  scar  on  the  anterior  face  is  turned  downward,  or 
the  inner  border  of  the  foot  may  be  raised  so  that  it  rests  on  the  outer 
border.  It  is  not  well  suited  to  cases  of  bone  disease  and  the  opera- 
tion is  now  seldom  practiced.  The  landmarks  have  been  given  for 
Lisfranc's  amputation  through  the  tar sometatarscd  joint  and  the  only  diffi,- 
culty  pointed  out,  i.  e.,  the  backward  projection  of  the  second  meta- 
tarsal bone  between  the  outer  and  inner  cuneiform  bones,  where  its 
chief  bond  of  union  with  the  tarsus  is  the  interosseous  ligament  that 
connects  it  with  the  inner  cuneiform.     Hey's  operation  avoids  the  diffi,- 


THE  TOES.  481 

culty  of  disarticulating  this  bune  by  sawing  tlirougli  it,  in  the  line  of 
the  other  joints.  Neither  operation  is  often  indicated  or  even  possible 
in  conditions  depending  on  accident  or  disease. 

Far  better  than  Chopart's  amputation  are  the  two  following  ampu- 
tations of  the  foot.  In  Symes'  amputation  (Jtc  iuci.'<ion  runs  from 
the  tip  of  the  outer  malleolus  vertically  downward,  then  transversely 
across  the  sole  and  vertically  up  on  the  inner  side  to  half  an  inch  below 
the  inner  malleolus.  This  brings  the  end  of  the  inner  incision  at  the 
same  height  as  the  external.  The  soft  parts  covering  tiie  heel  are 
dissected  carefully  away  from  the  calcaneum,  and  tJic  tough  skin  of  (he 
heel,  accustomed  to  bearing  pressure,  corcrs  the  .stump  left  by  sawing 
the  leg  bones  just  above  the  articular  cartilages.  The  skin  of  the  inner 
part  of  the  heel  flap  is  supplied  by  the  internal  calcaneal  branch  of 
the  external  plantar  artery,  and  it  is  most  important  for  the  life  of  the 
flap  not  to  cut  oif  this  blood  supply,  as  may  be  done  by  carrying  the 
internal  incision  further  back  than  directed. 

Pirogoff 's  amputation  closely  resembles  Symes'  except  that  the  incmon 
is  carried  a  little  further  forwcuxl ;  the  c(tlcnneum  i.s  .'^(nrn  througJi  in 
the  line  of  incision,  or  more  obliquely  ;  the  posterior  end  of  the  cal- 
caneum is  applied  to  the  under  sawn  surface  of  the  tibia ;  and  the 
tendo  Achillis  is  not  divided.  Owing  to  the  position  of  the  incision 
the  plantar  vessels  are  divided  further  forward  than  in  Symes'  operation, 
so  that  there  is  less  danger  of  gangrene  of  the  skin  on  the  inner  side 
of  the  heel.  In  amputation  of  the  great  toe  the  large  size  of  the  head 
of  the  first  metatarsal  bone  must  be  borne  in  mind,  so  as  to  cut  the 
flaps  large  enough  to  cover  it  and  bring  the  line  of  the  cicatrix  above 
the  plantar  surface,  for,  as  it  is  one  of  the  anterior  ends  of  the  longi- 
tudinal arch,  this  surface  is  subject  to  much  ])ressure. 

The  calcaneum  is  more  often  fractured  than  any  of  the  tarsal  bones. 
By  a  fall  on  the  heel  it  may  be  splintered  and  crushed,  especially  in  its 
anterior  half,  and  its  vertical  diameter  may  be  decreased,  so  that  the 
sole  is  flattened  and  the  malleoli  are  approximated  to  it.  By  a  forcil)le 
contraction  of  the  calf  muscles  the  calcaneum  has  occasionally  been 
fractured,  always  behind  the  astragalus  and  sometimes  only  the  back 
part,  which  attaches  the  tendo  Achillis.  The  latter  is  usually  ruptured 
in  place  of  fracture  of  the  calcaneum  from  muscular  violence.  The 
displacement  of  the  fragment  is  sometimes  slight,  sometimes  extreme, 
4J  inches  (Constance).  TJie  astragalus  alone  may  be  fractured  by 
falls,  but  the  lesion  is  often  associated  with  fracture  of  the  calcaneum, 
or  at  the  ankle,  etc.  Fracture  of  the  other  tar.s(d  l>o)ies,  the  iiie((d(tr.s(d 
and  the  phalange.^  is  commonly  due  to  direct  violence.  Such  fractures 
are  often  compound,  owing  to  the  scanty  covering  of  soft  parts  on  the 
dorsum  of  the  foot  which  are  usually  contused  or  lacerated. 

The  toes  very  closely  resemble  the  fingers,  exce})t  in  size,  and  are 
liable  to  similar  lesions  from  injury,  inflammation,  etc.,  tiiough  not  so 
frequently.  Dislocation  of  the  proximal  phalanx  of  the  great  toe  is 
similar  to  that  of  the  like  joint  of  the  thumb  in  the  character  of 
the  lesion,  the  difficulty  of  reduction  and  the  reasons  for  this  difli- 
31 


482  THE  LOWER  EXTREMITY. 

culty.  A  peculiar  affection  of  the  toes  known  as  "  hammer  toe,"  in 
which  the  proximal  phalanx  is  extended  while  the  middle  is  strongly 
flexed,  is  most  often  found  in  the  second  toe,  which  is  normally  longer 
than  the  others.  It  is  due  to  a  contraction  of  the  extensor  tendon 
and  of  the  glenoid  and  lateral  ligaments  of  the  first  phalangeal  joint. 

The  cutaneous  nerve  supply  of  the  lower  extremity  is  shown  by 
Figs.  118  and  119. 

Paralyses  of  the  lower  extremity  are  common  and  usually  due  to 
a  lesion  of  the  cord,  hence  they  involve  all  or  a  considerable  group  of 
nerves.  Occasionally  a  single  nerve  trunk  is  paralyzed  by  a  cord 
lesion  or  a  lesion  of  the  nerve  below  its  exit  from  the  spinal  foramen. 
This  involves  a  limited  area  of  anaesthesia  or  motor  paralysis.  An 
example  of  motor  paralysis  of  groups  of  muscles  is  seen  not  infre- 
quently after  infantile  paralysis. 

Paralysis  of  the  anterior  crural  nerve  may  be  due  to  fractures  and 
tumors  of  the  pelvis,  psoas  abscess,  dislocations  of  the  hip,  stab  wounds 
in  the  groin,  and  perhaps  a  partial  lesion  of  the  cauda  equina.  The 
patient  can  not  flex  the  hip,  as  in  rising  from  the  recumbent  position, 
(iliopsoas  and  pectineus),  or  extend  the  knee  (quadriceps).  The  sar- 
torius  is  paralyzed,  the  pectineus  partly  so,  being  supplied  in  part  by 
the  obturator.  In  the  parts  supplied  by  the  internal  and  middle 
cutaneous  and  long  saphenous  nerves  sensation  is  impaired. 

The  obturator  nerve  alone  is  seldom  paralyzed  but  may  be,  occa- 
sionally, from  the  pressure  of  the  foetal  head  or  an  obturator  hernia  or 
from  lesions  similar  to  those  paralyzing  the  anterior  crural.  The 
patient  can  not  adduct  the  thighs  or  cross  the  legs  (adductors)  and  out- 
ward rotation  of  the  thigh  is  impaired  (obturator  externus  and  adduc- 
tors).    Sensation  of  the  cutaneous  area  supplied  is  impaired. 

Paralyses  of  the  internal  or  external  popliteal  alone  are  not  common 
and  are  usually  due  to  traumatism  below  the  bifurcation  of  the  great 
sciatic.  In  paralysis  of  the  internal  popliteal  nerve  the  patient  can  not 
extend  the  ankle,  flex  or  stand  upon  the  toes  (muscles  of  the  back  of 
the  leg)  or  move  the  toes  laterally  (short  muscles  of  the  sole).  Ad- 
duction and  supination  of  the  foot  is  impaired  (tibialis  posticus).  The 
sensatioyi  in  the  skin  of  the  sole,  the  under  surface  and  ends  of  the  toes, 
and  the  lower  part  of  the  back  of  the  leg  is  impaired.  In  paralysis  of 
the  external  popliteal  nerve  the  patient  is  unable  to  flex  the  ankle,  abduct 
or  pronate  the  foot  or  fully  extend  the  toes  (anterior  leg  muscles  and 
peronei).  Hence  the  toes  drag  in  walking.  Adduction  and  su  pina 
tion  are  impaired  (tibialis  anticus).  Only  the  ends  of  the  toes  can*be 
extended  by  the  interossei.  Sensation  over  the  front,  outer  side  and 
part  of  the  back  of  the  leg  and  the  dorsum  of  the  foot  is  impaired. 

In  paralysis  of  the  great  sciatic  flexion  of  the  knee  is  lost  (hamstrings), 
and  external  rotation  of  the  thigh  is  impaired  (obturator  internus  and 
quadratus  femoris)  in  addition  to  the  results  of  paralysis  of  both  the 
internal  and  external  popliteal  nerves.  Paralysis  of  the  great  sciatic 
may  be  due  to  pelvic  tumors.  These  more  commonly  cause  a  neuralgia 
of  the  nerve.     Paralysis  or  neuralgia  of  the  individual  nerves  of  the 


PLATE    LV  I  1  1 


FIG.  118. 


FIG.  119. 


DORSAL    DIVI-   I 

SIONS    OF  I 

SACRAL  f 

NERVES  ) 

PERFORATING   I 

CUTANEOUS      I. 

OF    FOURTH       I 

SACRAL  J 


/i 


,'  0) 


EXTERNAL    SAPHENOUS    I.    II.    S. 

ANTERIOR    TIBIAL    IV.    V.    L.    I.    S 

EXTERNAL    PLANTAR-: 

INTERNAL    PLANTAR     IV.    V.    L. 


4?  <■• 


^^-if^'i 


INTERNAL     I 
CALCANEAN 


MUSCULOCUTANEOUS 
IW.    V.    L.    I.    S. 


Areas  of  distribution  of  ciiin- 
neous  nerves  of  the  front  of  the 
lower  limb.  ("W.  Keiller,  after 
Testut. ) 


Areas  cif  (list ribmion  of  cutn- 
neoLis  nerves  of  llie  back  of  the 
lower  limb.     (Testut.) 


NERVE  LESIONS  OF  THE  LOWER  EXTREMITY.  483 

lower  extremity  may  be  produced  by  similar  causes.  Hence  it  must 
be  borne  in  mind  that  pain  in  any  part  of  the  lower  extremity  may 
be  due  to  lesions  at  a  distance,  intra-spinal,  intra-abdominal,  intra- 
pelvic,  etc. 

In  the  diagnosis  of  the  situation  of  lesions  of  the  cord,  due  to  di.-^-ase 
or  fracture,  a  knowledge  of  the  skin  areas  and  the  muscles  of  the  lower 
extremity  supplied  by  the  several  segments  of  the  cord  is  important. 
For  this  see  chapter  on  the  spine. 


CHAPTER   yil. 


THE    SPINE. 


Landmarks  and  Topography. — The  first  spinous  process  that  is 
readily  palpable  is  that  of  the  seventh  cervical  (vertebra  prominens)  or 
sometimes  that  of  the  sixth  cervical.  Hence  we  begin  to  count  the 
spines  from  the  seventh  cervical.  The  first  thoracic  spine  is  still  more 
prominent  than  the  seventh  cervical.  The  third  thoracic  spine  is  on  a 
level  with  the  inner  end  of  the  spine  of  the  scapula ;  the  seventh  with 
the  lower  end  of  the  scapula  ;  the  fourth  lumbar  spine  with  the  highest 
part  of  the  iliac  crest  and  the  bifurcation  of  the  abdominal  aorta ;  the 
second  sacral  spine  with  the  posterior  superior  iliac  spine  and  the  center 
of  the  sacro-iliac  joint,  the  third  sacral  spine  with  the  upper  border  of 
the  great  sciatic  notch,  and  the  first  piece  of  the  coccyx  with  the  spine 
of  the  ischium.  The  umbilicus  is  on  a  level  with  the  interval  between 
the  third  and  fourth  lumbar  spines.  The  thoracic  spines  are  oblique 
and  overlap  one  another,  the  lumbar  are  horizontal  and  correspond  with 
the  vertebral  bodies.  The  trayisverse  proce.ss  of  the  atlas  is  palpable  a 
little  below  and  in  front  of  the  tip  of  the  mastoid  process,  the  anterior 
tubercle  of  the  sixth  cervical  vertebra  (^carotid  tubercle)  is  felt  on  a 
level  with  the  cricoid  cartilage.  The  bodies  of  the  upper  three  cervical 
vertebral  can  be  felt  through  the  mouth  at  the  back  of  the  pharynx, 
the  anterior  arch  of  the  atlas  being  on  a  level  with  the  hard  palate. 

The  spinal  column  is  required  to  serve  many  different  functions,  (1)  to 
bear  the  weight  of  the  head  and  upper  extremities,  (2)  to  give  attach- 
ment to  the  ribs,  (3)  to  serve  as  the  central  axis  of  the  body,  to  con- 
nect its  upper  and  lower  segments,  (4)  to  diminish  the  effect  of  shocks 
and  jars,  (5)  to  allow  of  varied  and  extensive  movements  and  yet  (6) 
to  provide  a  solid  canal  which  safely  contains  the  spinal  cord. 

Corresponding  to  the  increasing  weight  to  be  borne  by  the  vertebral 
bodies,  as  we  pass  from  the  upper  end  of  the  spine  to  the  sacrum,  we 
find  that  their  surface  area  gradually  increases  from  above  downward. 
To  allow  the  varied  and  extensive  movements  without  injury  to  the 
delicate  cord  within,  the  spine  is  composed  of  a  number  of  small 
articulated  segments,  the  movement  between  any  two  of  which  is  not 
great  but  that  of  the  spine  as  a  whole  is  very  considerable.  More  free 
movement  between  a  smaller  number  of  segments  would  not  only 
weaken  the  spine  and  make  it  more  liable  to  injury  but  also  expose 
the  cord  to  compression  by  being  sharply  bent. 

Of  the  four  antero-posterior  curves  only  two,  the  thoracic  and  sacral, 
are  present  at  birth.  These  are  primary  curves,  due  to  the  shape  of  the 
bones,  and  are  convex  backward  to  give  more  room  in  the  thoracic  and 

484 


CURVES  AND  CURVAl  URE  OF  THE  SPINE. 

Fig.  120. 


485 


CERVICAL 
VERTEBR>C 


THORACIC 
VERTEBR/E 


LUMBAR 
VERTEBRiC 


'<»' 


ilt^ 


The  spinal  column,  right  lateral  view  and  dorsal  view.    (Gkbrish,  after  Testut.) 

pelvic  cavitie.s,  which  they  help  to  form.  The  lumbar  and  crrrical 
CHiTCii,  convex  fnnrard,  are  principally  (htv  to  the  shape  of  the  interver- 
tebral discs.  They  appear  when  tiie  erect  position  is  assumed  and  are 
compensator y  curves  to  allow  the  child  to  sit  or  stand  erect.  Otherwise 
the  head  would  project  forward  and  a  marked  dor.sil  (xmvexity  would 
exist  in  the  thoracic  region.  This  position  is  seen  in  the  aged,  in 
whom  it  largely  depends  upon  the  shrinkage  of  the  discs,  wherel)y  the 
compensatory  curves  dependent  upon  them  are  flattened,  and  thus  the 
primary  permanent  thoracic  curve  is  exaggerated. 

The  normal  curves  of  the  spine  nun/  he  e.ra(/(/erated  so  as  to  constitute 
the  several  forms  of  ciirvature  of  the  spine. 

Increase  of  the  posterior  co)ivexifi/  in  the  thoracic  region  is  known  as 
kyphosis.    This  is  almost  always  due  to  a  tubercular  caries  of  the  bodies 


486 


THE  SPINE. 


Fig.  121. 


B 


A 


of  the  thoracic  vertebrse  and  is  known  as  "  Poffs  disease  of  the  spine'' 
When  the  aiFected  vertebral  bodies,  being  destroyed  by  the  ulceration, 
yield  to  the  pressure  of  the  superincumbent  weight  the  spine  bends  for- 
ward above  the  seat  of  the  disease  thereby  tJirowitif/  harkivard  the  sjiinous 
processes  opposite  the  diseased  area.  Tliis  gives  rise  to  an  angular  cur- 
vature or  hump  back,  which  is  accompanied  by  an  increase  of  the  cer- 
vical and  lumbar  compensatory  curves.  Hence 
to  avoid  deformity  in  spinal  caries  the  superin- 
cumbent weight  should  be  relieved  by  apparatus 
or  posture.  When  the  disease  attacks  the  cervical 
or  lumbar  vertebrae  there  is  no  angular  curvature, 
but  the  normal  posterior  concavity  of  these  regions 
is  flattened  out  and  the  affected  part  of  the  spine 
is  rendered  stiff.  The  neural  arches  and  the  cir- 
cumference of  the  vertebral  canal  almost  always 
escape. 

The  spinal  caries  is  often  associated  icith  abscess 
which  tends  to  sink  in  the  line  of  gravity  along 
the  spine.  Spinal  abscesses  in  the  thoracic  or 
lumbar  region  tend  to  enter  the  sheath  of  the  psoas 
muscle,  in  the  former  region  after  passing  beneath 
the  internal  arcuate  ligament.  They  are  the  com- 
mon cause  of  psoas  abscess.  If  the  curvature  is 
extreme,  or  comes  on  rapidly,  the  front  of  the 
cord  may  be  pressed  upon  by  the  projection  at 
the  back  of  the  vertebral  bodies  and  motor  paraly- 
sis results.  More  often  the  cord  symptoms  are  due 
to  the  pressure  of  inflammatory  thickenings,  de- 
posits or  abscesses  which  may  subside  from  general 
treatment ;  but  if  degenerative  changes  in  the  cord 
appear  the  spinal  canal  should  be  opened  to  remove 
the  cause  of  pressure.  In  recent  years  angular  curvatures  of  the  spine 
have  been  successfully  treated  by  forcible  straightening.  In  severe  cases 
the  chest  becomes  much  distorted  and  the  lower  ribs,  resting  on  the 
ilium  or  sinking  into  the  pelvis,  obliterate  the  iliocostal  space. 

Lordosis  is  an  increase  of  the  forvard  curve,  as  in  the  lumbar  and 
cervical  regions.  It  is  most  marked  and  most  often  observed  in  the  lum- 
bar region.  It  is  almost  invariably  a  compensatory  curve  instinctively 
assumed  to  keep  the  center  of  gravity  from  being  advanced  too  far  and 
to  allow  the  patient  to  stand  erect.  Thus  in  obesity,  pregnancy,  angular 
curvature,  congenital  dislocation  of  the  hips,  and  in  liip  disease  with 
flexion  of  the  femur  it  is  present  as  a  compensatory  curve.  The  latter 
condition  is  its  commonest  cause.  The  hip  being  held  or  anchylosed  in 
a  flexed  position,  the  patient  is  only  enabled  to  straighten  it  by  a  rota- 
tion of  the  entire  pelvis  by  which  its  upper  end  is  moved  forward, 
which  increases  the  lumbar  curve.  This  is  seen  in  examining  such  a 
patient  in  the  supine  position.  When  the  affected  extremity  is  extended 
the  lumbar  spine  is  arched  forward,  when  it  is  flexed  to  the  angle  in 


Diagrams  to  show  lor- 
dosis as  a  compensating 
curve  in  hip  disease.  A  ; 
normal  spinal  curves.  The 
hip  is  anchylosed  in  the 
flexed  position  ;  B ;  the 
anchylosed  flexed  hip  is 
straightened  by  a  tilting 
of  the  pelvis,  indicated  by 
the  position  of  the  dotted 
line  and  the  presence  of 
lordosis. 


LATERAL  CURVATURE. 


487 


Fig.   12-1. 


which  it  is  anchylosed  the  lumbar  curve  is  normal,  and  when  it  is  fur- 
ther flexed  tlie  curve  is  straightened  and  the  himbar  spines  press  tlie 
hand  against  the  table. 

Scoliosis  or  lateral  curvature  may 
also  be  said  to  be  an  exagyi  ration  of  a 
normal  curve,  for  very  few  are  without  a 
slight  lateral  spinal  curve  usually  to  the 
right  in  right-handed  persons.  Scoli- 
osis also  mat/  he  a  compcn.safori/  curve, 
compensating  the  lateral  tilting  of  the 
pelvis  which  accompanies  an  inequality 
of  the  length  of  the  legs.  It  may  be 
due  to  chronic  empyema,  or  the  ex- 
tensive resection  of  several  ribs  to  cure 
it.  3Iore  often  it  is  an  idiopathic  con- 
dition whose  etiology  we  really  do  not 
know  in  many  cases.  It  occurs  in 
children,  most  often  in  girls,  in  whom 
the  muscular  development  and  general 
condition  are  below  par.  A  faulty  atti- 
tude in  study,  etc.,  has  been  thought 
to  favor  it.  As  the  principal  curve,  in 
the  upper  thoracic  region,  is  Ufiualli/  con- 
vex to  the  right  in  right-handed  persons, 
unequal  muscular  action  is  thought  to 
be  a  causative  factor.  There  are  of 
course  compensatory  curves  in  the  op- 
posite direction  in  the  lumbar  and  cervi- 
cal regions  to  allow  the  erect  attitude. 
When  the  lateral  curve  has  reached  a 
certain  degree  the  vertebral  column  begins 
to  rotate  on  a  vertical  axis  so  that  the 

spines  turn    toward    the   concavity  of   the  right' in    the  thoracic    region,   the  com- 

f,  I  rrti  •  pensatorv  curves   in  the  opixisite  direo- 

CUrve,  tor  some  unknown  reason.        IniS  tiou  in  the  cervical  and  lumbar  regions. 

b.i  "  _  i.1         „       1"    _  The  vertebral  spines  are  shown   rotated 

rmgs   the    spmes    nearer    the    median  toward  the  concavity  of  the  curve. 

line  so  as  to   diminish  the  appearance 

of  the  curve  as  indicated  by  them.     It  also  carries  the  ribs  backward 

on  the  right  and  forward  on  the  left,  so  that  the  right  chest  is  full  and 

prominent  posteriorly  but  flattened  anteriorly,  while  the  left  chest   is 

prominent  in  front  but  its  ribs  are  crowded  together  and  its  capacity 

is  diminished.     In  time  the  vertebrie,  muscles  and  ligaments  become 

atrophied  and  contracted  on  the  concave  side,  stretched  on  the  convex 

side. 

The  spinal  canal  is  completed  posteriorly  by  the  fusion  of  the  lamina;, 

or  neural  arches,  at  the  root  of  the  spinous  processes.     Each  half  of 

the  neural   arch  is  formed    from  a  separate  ossitic  center.     Failure  of 

this  fusion  causes  a  posterior  median  defect  of  the  lamina?  and  spines 

which  is  seen  in  spina  bifida.     Phis  is  most  common  in  the  lumbosacral 


Diagram  to  show  lateral  curvature  of 
the  spine.    The  primary  curve  is  to  the 


488  THE  SPIXE. 

or  sacral  regions,  for  here  the  neural  arches  are  last  ossified.     Other 
imperfections  of  development  are  often  associated  with  spina  bifida. 

Spina  bifida  is  a  congenital  defect  of  the  vertebral  canal  through 
which  some  of  its  contents  protrude,  /.  e.,  (1)  the  membranes  alone 
(spinal  meningocele)',  (2)  the  membranes  with  the  cord  or,  generally, 
the  nerve  trunks  of  the  cauda  equina,  which  usually  adhere  to  the 
posterior  wall  of  the  sac  [ineningomyelocele) ;  (3)  the  latter  condition 
with  a  sac-like  dilatation  of  the  central  canal  of  the  spinal  cord 
(syringomyelocele).  The  second  variety  is  the  most  common,  the  first, 
the  next,  and  the  third  the  rarest.  In  all  forms  the  sac  is  filled  with 
cerebrospinal  fluid,  almost  always  from  the  subarachnoid  space  (i.  e.,  in 
the  first  two  forms).  Hence  the  sac,  which  forms  a  median  dorsal 
tumor,  is  more  tense  in  the  upright  position  and  on  crying.  Pressure 
may  return  some  of  the  fluid  and,  by  increasing  the  pressure  within 
the  spinal  canal,  may  result  in  causing  irregular  muscular  movements 
or  even  convulsions. 

The  twenty-three  intervertebral  discs  make  up  nearly  one  fourth  of 
the  length  of  the  spine,  hence  the  height  of  the  body  is  appreciably  de- 
creased from  their  compression  on  long  standing  or  sitting,  and  in  old 
age  from  the  shrinkage  of  the  discs.  It  is  owing  to  the  discs  that  the 
movements  of  the  spine  are  permitted,  and  these  movements  are  most 
free  where  the  vertebrse  are  smallest  or  the  intervening  discs  thickest, 
i.  e.,  in  the  cervical  and  lumbar  regions  respectively.  Therefore  move- 
ment is  most  free  where  the  spinal  canal  and  cord  are  the  largest,  where 
the  curve  is  convex  forward,  and  where  there  are  no  bony  cavities 
containing  viscera.  Free  movement  in  the  thoracic  region  would 
be  a  distinct  disadvantage  to  the  thoracic  viscera.  Movement  is  per- 
haps most  free  in  the  lumbar  region,  but  rotation  and  lateral  motion 
is  freest  in  the  cervical  region  and  extension  is  as  free  there  as  any- 
where. 

The  vertebral  bodies  with  the  intervening  pulpy  portion  of  the  discs 
really  form  ball  and  socket  joints,  but  the  free  movements  thereby 
allowed  are  resisted  by  the  connecting  ligaments  and  restricted  by  the 
articular  processes  and  in  parts  by  the  other  processes  of  tlie  vertebrte. 
Owing  to  the  more  or  less  horizontal  surfaces  of  the  articular  processes 
of  the  cervical  region  movements  in  all  directions  are  permitted  there. 
Rotary  movements  are  most  free  in  the  atloaxoid  joints,  flexion  and 
extension  in  the  occipitoatloid  joints.  In  the  thoracic  region  extension 
is  prevented  by  the  overlapping  spines  and  by  the  shape  of  the  artic- 
ular processes.  The  latter  limit  flexion  also,  whereas  lateral  move- 
ments, otherwise  possible,  are  prevented  by  contact  between  the  ribs. 
In  the  lumbar  region  lateral  movements  are  limited  by  the  great  trans- 
verse diameter  of  the  bodies,  rotation  by  the  relation  of  the  articular 
processes. 

The  overlapping  lamina  protect  the  cord  from  injury  in  the  thoracic 
region  where,  owing  to  the  curve,  it  lies  nearer  the  surface  and  is  most 
exposed.  Between  the  upper  cervical  vertebnc  the  intervals  between  the 
narrow  laminae  are  widest  and  here  the  cord  can  be  most  easily  reached 


DISLOCATION  OF  THE  SPINE.  489 

and  toounded  by  a  narrow  instrument.  Infanticide  has  been  accom- 
plished by  pithing  the  upper  cervical  cord  Ijy  a  long  narrow  pin, 
thrust  between  the  upper  cervical  vertebrae  or  between  the  atlas  and  the 
occiput.  Again  in  the  lumbar  region  it  is  posaihle  to  enter  tlie  Mjiinal 
canal  by  an  instrument  thrust  obH(jiiely  upward  and  forward.  This 
is  taken  advantage  of  in  lumbar  puncture  and  spinal  cocainization.  The 
puncture  is  made  between  two  lumbar  spines  below  the  second  lumbar 
vertebra  (usually  between  the  third  and  fourth),  to  avoid  the  cord 
which  extends  to  the  lower  end  of  the  first  lumbar.  To  avoid  the  spines 
the  puncture  is  made  a  little  (\  to  1  cm.)  to  one  side  of  the  median  line. 
In  adults  the  puncture  is  made  opposite  the  middle  of  the  spine  below 
the  interval,  to  give  the  needle  the  desired  ui)war(l  obliquity.  77// 
needle  is  then  thrust  forward,  toward  the  middle  line,  and  in  adn/ln 
slightly  upward,  for  2  to  7.5  cm..,  until  the  esca])e  of  fluid  (cerebro- 
spinal) indicates  that  its  point  has  entered  the  subarachnoid  space. 
The  canal  is  entered  through  the  ligamentum  sul)rtavum.  The  j)ossible 
puncture  of  one  of  the  nerves  of  the  cauda  equina  may  occur  and  is 
shown  by  the  twitching  of  some  of  the  muscles  of  the  lower  extremity. 
On  account  of  the  number  of  the  joints  and  ligaments  of  the  spine 
and  the  variety  and  extent  of  its  movements  it  is  readily  understood 
why  the  .^pine  is  liable  to  sprains.  These  naturally  occur  most  often 
where  the  movements  are  most  free,  in  the  lumbar  and  cei'vical  regions. 
The  nearness  of  the  head  and  the  transmission  of  violence,  received  by 
it,  to  the  spine  may  increase  the  tendency  to  sprains  in  tiie  cervical 
region.  Considerable  pain  and  stiffness  often  persist  long  after  the 
injury,  and  these  may  depend  upon  a  synovitis  of  one  or  more  of  the 
many  vertebral  joints.  Ecchymosis  rarely  appears  in  these  cases, 
for  the  spine  is  separated  from  the  skin  by  many  layers  of  muscles 
and  fasciae. 

When  the  violence  applied  is  more  concentrated  or  more  severe  frac- 
tures or  dislocations  of  the  spine  are  produced.  The  Habilifi/  of  the 
spine  to  these  accidents  is,  to  be  sure,  di)nini.'<lied  by  its  elasticity,  due  to 
its  curves,  its  discs,  etc.,  and  by  the  number  of  its  segments.  Some  have 
even  denied  the  possibility  of  dislocation  of  the  spine  without  fracture, 
except  perhaps  in  the  cervical  region,  where  the  small  size  of  the  bodies 
and  the  more  horizontal  direction  of  the  articular  processes  do  not  offer 
so  much  resistance  to  the  separation  of  the  vertebne.  But  in  many 
cases  the  associated  fracture  is  unessential  to  the  ])roduetion  of  the 
dislocation. 

Dislocation  is  mod  common  in  the  cervical  r<'7/o;j,  especially  between 
the  fourth,  fifth  and  sixth  vertebne,  less  common  in  the  thoracic,  and 
exceedingly  rare  in  the  lumbar  region.  The  dislocation  may  be  com- 
plete or  incomplete,  bilateral  (dislocation  by  flexion)  or  unilateral  (dis- 
location by  abduction  or  rotation).  In  the  latter  form  only  one  side 
of  the  vertebne  is  dislocated  and  the  axis  of  its  displacement  passes 
throuHi  the  other  side.  But  as  most  dislocations  of  the  spine  are 
partly  dislocation  and  partly  fracture,  and  as  it  is  usually  impossible 
to  distinguish  between  them,  furthermore  as  the  effects  of  the  two  are 


490  THE  SPINE. 

similar,  it  is  best  to  consider  them  together.  The  term  fracture-dis- 
location is  often  applied  to  all  such  injuries  of  the  spine. 

Fracture  of  the  spine  may  be  due  to  indirect  or  direct  violence. 
Those  due  to  the  latter  are  rare  and  usually  confined  to  the  spines  and 
laminae  in  the  thoracic  or  cervical  region,  or  at  least  to  the  posterior 
portions  of  the  vertebrae.  The  injury  to  the  cord  is  less  severe  and 
less  common  as  a  rule  in  this  class  of  cases,  for  much  displacement  is 
rare. 

Fractures  from  indirect  violence  are  usually  due  to  a  forcible 
bending  of  the  spine  in  a  fall  or  by  the  weight  of  a  falling  body. 
The  breaking  of  the  neck  by  diving  in  shallow  water  is  an  example. 
Tlie  rekdive  frequency  of  the  injury  in  the  lower  cervical  sjnne  and  at 
the  thoracico-lumbar  junction  may  be  partly  explained  by  the  free 
mobility  at  these  points,  by  the  fact  that  at  these  points  a  flexible  and 
a  rigid  portion  of  the  spine  meet  and,  in  the  cervical  region,  by  the 
small  size  of  the  bodies.  Both  regions  where  fractures  are  of  common 
occurrence  are  far  enough  from  the  ends  of  the  spine  to  be  aifected  by 
powerful  leverage  from  both  sides.  The  sternum  and  ribs  may  also 
act  to  some  extent  as  a  splint  to  protect  the  thoracic  part  of  the  spine. 
As  the  fractures  are  due  to  forced  flexion  the  anterior  portions  of  the 
bodies  may  be  more  or  less  crushed,  while  the  neural  arches  are 
pulled  apart.  It  is  noticeable  that  the  large  cancellous  bodies 
are  well  adapted  to  resist  compression  while  the  neural  arches  and 
their  connecting  ligaments  are  well  suited  to  resist  traction.  The 
various  processes  may  also  be  fractured,  in  the  cervical  region  in  50  per 
cent.,  in  the  thoracic  region  in  12.5  per  cent.,  and  in  the  lumbar 
region  in  14  per  cent.  The  following  is  the  order  of  relative  frequency 
for  the  various  regions  and  processes ;  the  spines  in  the  thoracic,  cer- 
vical and  lumbar  regions ;  the  transverse  processes  in  the  cervical, 
lumbar  and  thoracic  regions ;  the  articular  processes  in  the  cervical, 
thoracic  and  lumbar  regions.  Fracture  of  the  articular  processes 
increases  the  liability  of  displacement  by  removing  one  of  the  pos- 
terior processes  which  tend  to  lock  the  vertebrae  together. 

In  the  cervical  and  thoracic  regions,  particularly,  the  displaced  parts 
may  often  be  returned  to  the  normal  position.  This  may  occur  sponta- 
neously, so  that  on  examination  no  irregularity  of  contour  is  discovered, 
or  it  may  be  done  by  the  surgeon,  more  readily  after  dislocation  than 
after  fracture.  The  line  of  fracture  is  usually  nearer  the  upper  than 
the  lower  surface  of  the  bodies  and  there  is  more  or  less  laceration  of 
the  contiguous  disc  in  all  cases,  as  well  as  of  the  ligaments  connecting 
the  spines,  laminae  and  articular  processes.  The  injury  to  the  bones 
is  the  least  important  part  of  fracture  dislocations  of  the  spine,  that  of 
the  contained  cord  is  the  most  so.  The  latter  from  its  size,  which  is 
smaller  than  that  of  the  canal,  and  from  its  method  of  suspension  in 
the  vertebral  canal  (see  p.  492)  may  escape  injury,  and  is  injured 
only  when  the  lumen  is  considerably  encroached  upon  by  the  displace- 
ment of  the  fragments.  This  displacement  is  almost  always  of  the 
upper  fragment  forward,  or  perhaps  forward  and  downward,  on  the 


THE  SPINAL  CORD.  491 

lower.  Tlie  cDrd  is  thus  coinpressed  af/ahwf  the  sluirj)  ptj.sterior  edge  of 
the  vertebral  body  below  the  line  of  fracture.  Thus  the  antrrior  or 
motor  j)ort  ion  of  the  cord  unfferti  first  and  Jo  rr  mod  and,  if  the  crushing  of 
the  cord  is  not  complete,  sensation,  which  is  conducted  in  the  posterior 
part,  may  bo  retained  in  whole  or  in  part.  Tlw  nfiexes  centering  in 
the  central  gray  matter  may  also  be  preserved. 

The  symptoms  are  largely  those  of  the  injury  to  the  eord.  In  fractures 
in  which  there  is  or  has  been  no  displacement  there  may  be  almost  no 
symptoms,  except  those  resembling  a  severe  sprain,  or  |)erha|)s  those 
due  to  hemorrhage.  Tlw  external  defonnili/  nhons  only  a  displacement 
of  the  vertebrte  or  a  lesion  of  the  laminie  and  spinous  processes.  This 
external  deformity  consists  in  an  antero-posterior  or  lateral  deviation 
of  the  spines  at  the  point  of  injury. 

7Vic  spinal  canal  i-s  opened  hii  laminectomy  in  certain  cases  of  fracture 
dislocation  of  the  spine,  especially  when  the  symptoms  do  not  indicate 
a  complete  crushing  of  the  cord  or  when  the  lesion  is  below  the  level 
of  the  cord  in  the  region  of  the  cauda  equina,  as  well  as  in  some  cases 
of  pressure  paralysis  with  beginning  degeneration  in  Pott's  disease,  and 
in  cases  of  tumors  within  the  canal.  The  cord  is  then  relieved  of  pres- 
sure by  the  removal  of  its  cause.  In  this  operation  the  spines  and 
lamincB  are  removed,  the  latter  as  near  as  possible  to  the  transverse  proc- 
esses. The  spines  and  laminte  are  exposed  by  a  free  median  incision 
and  by  the  detachment  and  retraction  to  either  side  of  the  overlying 
muscles.  Plexuses  of  veins  on  the  outer  and  inner  surfaces  of  the 
laminae  and  along  the  spines  may  give  rise  to  considerable  venous 
bleeding. 

The  Spinal  Cord. 

Topography. — The  spinal  cord  extends  to  the  end  of  the  spinal  canal 
in  early  fcjetal  life,  to  the  third  lumbar  vertebra  at  birth  and  to  the 
lower  end  of  the  first  lumbar  vertebra  in  the  adult.  It  is  raised  I 
cm.  when  the  body  is  bent  forward  and  the  arms  are  raised.  The 
spinal  membranes,  containing  cerebrospinal  fluid,  reach  to  the  level  of 
the  third  sacral  spine,  so  that  injuries  here  may  i)rotluce  spinal  menin- 
gitis. The  cervical  enhirfjemcni  is  opposite  the  fifth  and  sixth  cervical 
vertebra?  and  measures  13  mm.  transversely,  the  lumhar  enlarr/emenf  is 
largely  opposite  the  twelfth  thoracic  vertebra  and  measures  12  mm. 
transversely.  In  the  thoracic  region  the  C(M*d  measures  10  mm.  trans- 
versely and  8  mm.  antero-posteriorly.  It  averages  H  feet  in  length 
and  1?,  ounces  //;  u-eight. 

The  manner  in  which  the  cord  is  suspended  within  the  vertebral 
canal,  which  it  does  not  nearly  fill,  accounts  in  part  for  its  frei|uent 
escape  from  injury.  The  strong  spinal  dura  forms  a  tubular  sheath 
(theca)  for  the  cord  and  an  investment  for  each  nerve  as  it  passes 
through  it.  It  is  continuous  u-ith  the  dura  of  the  cranium  but, 
unlike  it,  does  not  serve  as  the  j)eriosteum  of  the  bones  bounding  the 
canal,  but  is  sej)arated  from  them  by  a  considerable  interval  containing 
loose  areolar  and  fatty  tissue  and  })lexuses  of  veins.  The  latter  may 
give  rise  to  extensive  hemorrhage  in  injuries  to  the  spine^  and  the 


492  THE  SPINE. 

extravasated  blood  tends  to  gravitate  toward  the  lower  level  of  the 
canal,  where  sufficient  quantity  may  collect  to  cause  pressure  symptoms. 
So  tough  and  loosely  connected  with  the  bones  is  the  dura  that  it  is  usu- 
ally  untorn,  even  when  the  cord  is  completely  crushed  by  a  fracture. 
Inflammation  of  the  dura  and  also  of  the  underlying  meninges, 
after  injuries  of  the  spine,  is  much  less  frequent  than  similar  compli- 
cations after  injuries  of  the  skull.  By  the  communication  through 
the  ligamenta  subflava  between  the  dorsal  spinal  veins,  on  the  posterior 
aspect  of  the  neural  arches,  and  the  venous  plexuses  within  the  canal 
inflammation  may  travel  from  without  to  the  spinal  meninges.  In 
this  way  spinal  meningitis  has  followed  carbuncle  at  the  back  of  the 
neck  or  deep  bed-sores  over  the  sacrum. 

The  subdural  space,  or  the  space  between  the  dura  and  arachnoid, 
in  the  spinal  canal  is  merely  a  potential  one,  the  two  membranes  being 
normally  in  contact.  The  subarachnoid  space,  however,  contains  a  large 
amount  of  cerebrospinal  fluid  which  surrounds  the  cord.  The  cord  is 
suspended  in  this  fluid,  being  connected  with  the  layers  of  the  meninges 
just  mentioned  only  by  the  nerve  roots  and  the  ligamentum  denticu- 
latum  on  either  side,  and  the  septum  posterius  behind.  These  processes 
serve  to  steady  the  cord,  surrounded  by  fluid,  in  its  position  within 
its  theca. 

This  fluid  is  continuous  with  the  subarachnoid  fluid  about  the  brain 
and,  through  the  foramen  of  Magendie,  with  that  within  the  cerebral 
ventricles.  Thus  in  the  case  of  a  spina  bifida,  which  contains  this  same 
fluid,  fluctuation  may  sometimes  be  felt  at  the  anterior  fontanelle  on 
compressing  the  tumor,  and  when  the  fluid  is  drained  from  a  spina 
bifida  so  much  may  escape  that  the  brain  loses  the  support  of  its  water 
bed  and  convulsions  may  occur  from  its  irritation.  Convulsions  may 
also  occur  in  lumbar  puncture  if  the  pressure  is  too  much  reduced. 
The  normal  pressure  of  this  fluid  in  the  recumbent  position  is  said  to 
support  a  column  of  water  two  inches  high,  but  in  inflammation  and 
some  other  diseased  conditions  it  may  reach  many  times  that  amount. 
Normally  the  fluid  is  absorbed  when  its  pressure  is  greater  than  that 
in  the  surrounding  veins,  and  in  diseased  conditions  the  pressure  may 
be  relieved  by  lumbar  puncture.  In  spinal  cocainization  as  much  fluid 
is  withdrawn  as  solution  is  to  be  introduced,  so  as  not  to  alter  the 
pressure.  The  percentage  of  albumin  in  this  fluid  is  very  low,  .05  per 
cent.,  far  below  that  of  blood  serum,  but  it  is  greatly  increased  in  in- 
flammation and  thus  is  a  diagnostic  sign.  Lumbar  puncture  is  also 
useful  diagnostically  by  allowing  a  bacteriological  and  microscopical 
examination  of  the  fluid,  and,  as  this  fluid  comes  from  about  the  brain 
as  well  as  the  cord,  it  is  useful  in  some  cerebral  conditions.  Thus 
tubercle  bacilli  are  often  found  in  cases  of  tubercular  meningitis  and 
the  diplococci  of  cerebrospinal  meningitis  in  cases  of  the  latter.  The 
presence  of  numerous  cells  indicates  inflammation  and  that  of  blood  a 
pachymeningitis  or  an  injury.  Therapeutically  it  has  proved  of  little 
value.  It  suggests  itself  in  hydrocephalus,  but  is  nothing  more  than 
palliative.     In  a  few  cases  of  spinal  injury  it  appears  to  have  been 


PLATE    LIX. 


FIG.  123. 


ANT.    NCRVC 
BOOTS 


Lie.    OCNTIC- 
ULATUM 


'»y^l       POST.    NERVr 
Vfi\  ROOTS 


SPACE 


Section  of  the  cord  and  its  memlDranes  to  show  the 
inannep  of  suspension  of  the  corci  wiiliin  the  vertebral 
canal.     Diagrammatic.    (Testut. ) 


CONDUCTION  PATHS   OF   THE   CO  HI).  493 

serviceable.  By  means  of  the  free  communication  establi.slicd  hy  this 
fluid  between  the  spinal  and  cranial  cavities  it  affords  a  rcadv  means 
of  the  spread  of  inflammation  from  one  to  the  other.  Blood  extra- 
vasated  into  the  subdural  or  subaraclinoid  spaces,  in  case  of  injury,  may 
readily  extend  from  end  to  end  of  the  cord  and  tends  to  gravitate 
toward  its  lower  end,  but  extensive  hemorrhage  in  these  spaces  is  not 
common. 

In  spite  of  the  marvelous  provision  for  protection  of  the  cord  a  train 
of  severe  and  complicated  symptoms  sometimes  follows  certain  injuries 
to  the  spine.  These  symptoms  are  attributed  by  some  to  concussion  of 
the  cord,  comparable  to  concussion  of  the  brain,  but  they  arc  more 
complex  than  the  symptoms  of  the  latter.  The  explanation  of  those 
symptoms  as  due  to  certain  molecular  changes  in  ti»e  cord  is  disputed 
by  most  surgeons,  partly  on  the  anatomical  ground  that  the  provisions 
for  the  protection  of  the  cord  would  not  admit  of  such  a  lesion.  Such 
symptoms  prohahli/  depend  upon  a  distinct  /e.^ion  of  the  cord,  such  as 
hemorrhage  (li(rmatomi/clia),  the  diagnosis  of  which,  says  Tiiorlturn, 
when  tlie  symptoms  may  be  attributed  to  a  single  focus  of  injury, 
"should  always  be  preferred  to  the  vague  and  unsatisfactory  designa- 
tion 'concussion  of  the  spinal  cord.'"  Many  supj)osed  cases  of  the 
latter  will  probably  be  eliminated  by  accurate  study.  The  lenton  is 
probably  due  to  a  partial  dislocation  with  recoil,  an  acute  bend,  or  a 
diastasis  (separation)  of  the  spine. 

Compression,  contusion  or  crushing  of  the  cord  is  what  coni<ti- 
tutes  the  gravity  of  fractare-dislorationx  of  the  spine.  Compression 
may  also  be  due  to  tumors,  inflammatory  dej)osits,  etc.  As  stated 
above,  in  fracture-dislocations  with  displacement  the  cord  is  compressed 
or  crushed  by  being  pressed  by  the  neural  arch  above  the  line  of  frac- 
ture against  the  sharp  postero-superior  edge  of  the  body  below  the 
fracture  line.  The  anterior  part  of  the  cord  is  therefore  first  and, 
when  the  entire  cord  is  not  crushed,  most  affected  by  the  injury. 

It  is  important  therefore  both  for  diagnosis  and  prognosis  to  know 
something  of  the  conduction  paths  of  the  cord.  Tlie  direct  pyramiddl 
tract,  or  column  of  Tiirek,  in  the  mesial  part  of  the  ventral  column, 
conveys  motor  fibers  from  tlie  cortex  on  the  same  side,  which  have  not 
crossed  in  the  pyramids.  They  eventually  reach  the  oi)positc  sitle  by 
passing  through  the  anterior  white  commissure.  The  crossed  pyramidal 
tracts  lie  in  the  ])ostoro-mesial  jKirt  of  tlie  lateral  columns  and  convey 
motor  fibers  which  have  crossed  in  the  i)yrainid  from  the  »-ortex  of  the 
opposite  side.  Lesions  of  these  two  columns  cause  a  paralysis  of  the 
muscles  below.  The  muscles  arc  not  atrophied  unless  the  anterior 
cornu  of  gray  matter  is  involved.  The  direct  cerebellar  tract  on  the 
postero-lateral  aspect  of  the  hiteral  cohunn,  separating  the  crossed 
pyramidal  tract  from  the  periphery,  ami  the  dorso-lateral,  or  Burdaeh's 
column,  are  ascending  or  sensory  tracts  carrying  sensory  impn'ssions 
upward.  They  and  the  sensory  or  posterior  horn  of  tlie  gray  matter 
are  situated  on  the  dorsal  asj)ect  of  the  cord.  The  colinnn  of  liunlach 
also  contams  fibers  that  coordinate  niiis<-iilar  movements  »o  that  in  lesions 


494  THE  SPINE. 

of  this  part  there  is  ataxia  in  addition  to  peripheral  pains  and  impaired 
sensation.  In  the  antero-lateral  column  are  i\\e  fibers  irhich  inhibit  the 
reflexes  and  thus  keep  them  under  control  of  the  brain.  When  the 
lesion  involves  these  fibers  the  inhibitory  control  of  the  brain  is  lost, 
the  reflexes  are  exaggerated  and  a  spastic  contraction  results,  which,  in 
connection  with  the  motor  paralysis,  is  called  spastic  paraplegia.  Sub- 
sequently the  muscles  become  contractured.  If  the  reflex  centers  are 
destroyed  the  reflexes  are  lost.     These  centers  are  in  the  gray  matter. 

The  distinction  between  total  and  partial  transverse  lesions  is  im- 
portant. In  partial  transverse,  lemons,  when  paralysis  and  anaesthesia 
are  complete  but  the  deep  reflexes  are  exaggerated  or  normal,  or 
when  the  anresthesia  is  not  complete,  operation  (laminectomy)  offers 
some  hope  and  is  justifiable.  Many  condemn  operation  in  complete 
transverse  lesions  on  the  ground  that  the  case  is  hopeless,  but  it  is  not 
invariably  so,  and  in  many  such  cases  great  improvement  or  nearly 
complete  cure  has  resulted.  The  reparative  power  of  the  cord  is  great, 
so  that  after  severe  crushing  the  function  may  be  recovered  to  a  greater 
or  less  extent.  Recent  experience  in  the  surgery  of  the  cord  is  on  the 
whole  encouraging.  The  cauda  equina  and  the  nerve  roots  are  prac- 
tically periphercd  nerves  and  hence  resist  trauma  well,  so  that  operation 
should  be  the  rule  in  injuries  of  the  cauda  equina,  especially  if  after  six 
to  ten  M'eeks  the  bladder  and  rectum  symptoms  persist. 

The  determination  of  the  level  of  the  lesion  is  important  not  only 
in  traumatic  lesions,  but  even  more  so  in  those  due  to  a  tumor  or  an 
inflammatory  deposit.  For  this  purpose  there  are  three  means  at  our 
disposed:  the  extent  (1)  of  the  sensory  paralysis  and  (2)  of  the  motor 
paralysis,  and  (3)  the  condition  of  the  reflexes  of  each  segment.  From 
these  we  can  judge  what  nerves  and  therefore  what  spinal  segments  are 
involved.  The  cord  is  divided  into  as  many  segments  as  there  are  spinal 
nerves.  Each  segment  includes  the  roots  of  a  pair  of  spinal  nerves,  the 
dividing  line  between  two  adjoining  segments  passing  transversely  be- 
tween the  superficial  origins  of  the  pairs  of  nerve  roots.  Remember 
that  the  cervical  nerves  appear  above  their  respective  vertebrae,  the 
thoracic  and  lumbar  nerves  below. 

It  is  most  important  to  remember  that  tJic  level  of  the  secpnent,  or  the 
superficial  origin  of  the  nerve  from  the  cord,  is  higher  titan  the  exit  of 
the  nerve  through  an  intervertebral  foramen.  In  other  words  the  nerve 
roots  run  without  the  spinal  canal  and  alongside  of  the  cord  for  a  dis- 
tance which  varies  with  different  nerves  and  is  greater  in  the  lower 
part  of  the  cord.  These  nerve  roots  resist  injury  far  better  than  the 
soft  cord,  so  that  as  a  rule  the  nerve  roots  which,  given  off  above,  pass 
the  site  of  the  cord  lesion  are  seriously  involved  only  in  the  most 
severe  injuries.  It  follows  that,  the  site  of  the  fracture  being  known, 
when  the  anaesthesia  extends  to  this  level  the  lesion  is  so  severe  as  to 
crush  the  nerve  roots  as  well  as  the  cord  and  the  prognosis  is  corre- 
spondingly bad.  As  a  rule,  we  must  expect  the  level  of  the  paralysis 
and  ancesthesia  to  be  loiver  than  the  vertebral  lesion  by  the  length  of  the 
intraspinal  course  of  the  nerve  roots  at  that  point.     The  nerves  whose 


LOCALIZATION  OF  LESIONS  OF  THE  CORD.  495 

roots  pass  the  lesion  may  perhaps  show  gome  parsesthesia,  hyporees- 
thesia  or  pain,  but  the  pain  like  the  aniesthesi:i  is  almost  always  referred 
to  a  lower  level  tlian  the  lesion,  on  account  of  the  intnuspina'l  course  of 
the  nerve  roots.  Horsley  says  it  is  necessary  to  very  accurately  deter- 
mine the  upper  border  of  the  hypera?.sthetio  and  pariL-sthctic  zones, 
above  the  anjcsthetic  zone,  and  the  cord  should  be  <'.\pl(»red  to  the 
highest  level  suggested  by  any  definite  symptoms,  including  even 
slight  parsesthesia.  This  is  especially  important  as  it  is  the  experi- 
ence of  many  operators  to  have  found  the  lesion  higher  than  it  had 
been  placed  by  the  neurologist. 

The  following  table  gives  the  points  of  origin  of  the  mrve  roots  from 
the  cord  irith  nfcrencc  (l)  to  the  bodies  and  (2)  to  the  spines  of  the  verte- 
brae opposite  them  : 


Between  the f>ccipiit  and 
the  sixth  V.  npine. 
These  spines,  except 
the  latter,  cannut  l>e 
felt. 


First  cervical  nerve Interval  between  atlas  and 

occiput 

Second  and  third  cervical  nerves..opposite  the  axis 

Fourth  to  eighth  "     "(incl. )  op.  third  to  seventh  C.  ver- 

tehne  respectively. 

First  thoracic  nerve op.  disc  below  seventh  C. 

vertebra Seventh  C.  spine. 

Second     "  "      op.  disc  below  first  T.  ver- 

tebra. 

Third       "  "      op.   disc  below  second  T. 

vertebra First  T.  spine. 

Fourth     "          "      op.  disc  below  third  T.  ver- 
tebra       Second  T.  spine. 

Fifth  and  sixth  thoracic  nerves... op.  lower  border  of  fourth 

and  fifth  T.  vertebra-  re- 
spectively      Third    and    fourth    T. 

spines  respectively. 

Seventh  to  twelfth       "     "(incl. )  op.  lower  border  of  sixth 

to  eleventh  T.   vertebne 

respectively Fifth  to  tenth  T.  spines 

respectively. 
First  to  third  lumbar  nerves op.  twelfth  thoracic  verte- " 

bra 

Fourth  "       nerve op.  disc  below  twelfth  T. 

vertebra 

Fifth  "  "     op.    upper  border  first  L. 

vertebra 

First  to  fifth  sacral  nerves  (incl.  )..op.  first  L.  vertebra First  L.  spine. 

The  areas  of  ancvdhesia  corresponding  to  tlie  several  segments  of  the 
cord  are  seen  by  reference  to  Fig.  124.  It  will  be  seen  that  only  when 
the  first  lumbar  segment  is  involved  does  the  anjosthesia  extend  up  to  the 
abdominal  wall.  Wy  the  area  of  auiosthesia  alone  it  is  impossible  to 
definitely  determine  lesions  of  the  eauda  equina  from  tho.se  of  the  seg- 
ments from  which  they  are  derived.  In  all  cases  the  localization  of 
the  injury  of  the  cord  must  he  made  from  the  symptoms  observed 
shortly  after  the  injury  for  within  a  few  days  myelitis  is  aj)t  to  oceiir 
and  cause  an  extension  of  the  area  of  amesthesia  and  panily.'^is. 

For  the  interpretation  of  the  nmscuhir  parahisis  three  methods  of  de- 
termininr/  the  localization  of  the  seffinents  which  correspond  to  the  nerve 
supply  of  the  muscles  hare  hem  emphi/cd :  (1)  the  ex[)erimental,  on 
monkeys,  (2)  the  clinical  from   an   accurate  observation  of  ca.ses,  and 


Opposite   eleventh   and 
twelfth  T.  spini's. 


496 


THE  SPINE. 


(3)  the  anatomical  from  minute  dissections.  Although  perhaps  less 
accurate  than  the  others  the  clinical  method  is  still  of  the  mod  practical 
service  and  hence  column  D  of  Fig.  125  gives  the  results  obtained  by 
Thorburn  from  an  analysis  of  careful  clinical  observations. 


Fig.  124. 


Cutaneous  sensory  distribution  of  the  spinal  segments  on  the  anterior  and  posterior  surfaces,  from 
the  third  cervical  to  the  fourth  sacral,  inclusive.     (After  Kocher.) 

According  to  Thorburn  no  motor  supply  comes  from  the  first  and 
second  lumbar  segments  but  many  derive  part  or  the  whole  of  the 
nerve  to  the  cremaster  from  them.  It  will  be  seen  that  motor  paraly- 
sis is  slight  in  the  lower  cord  lesions,  only  the  perineal  muscles,  bladder 
and  rectum  being  involved  in  lesion  just  below  the  second  sacral  seg- 
ment and,  with  the  possible  exception  of  the  glutei,  only  the  leg  and 
foot  muscles  are  affected  if  the  lesion  involves  all  the  sacral  segments. 
In  pressure  lesions  of  the  cauda  equina  the  pressure  may  be  sufficient  to 
cause  Avidespread  paralysis  when  sensation  is  but  slightly  affected.    Also 


Fio.  125. 


euPIUIPINATU*. 
lhfRAAPI*«ATUB  I 

TtUti  UINON.    I  I 

25_il'l';t>'».  Bfl*C>1l»l.l». 
DCL70ID.  UrUCHtO- 

SUPINATOR 
6U"ICAI>    PKOHATOW 
M/IJ,  LATIU.  PICT 
TniCCP».«eilll.UAC 
CXTENtOnS  OP  WRIIT. 

PLEXOm  Of  THE  WRIST 

INTER0S8CIAN0  OTHER 
INTRINSIC  WUSCt.CS  OP 
>IAND, 


V  INTERCOSTAL 
f       MUSCLES. 


D. 

E. 

F. 

MOTOR 

SENSORY 

REFLEXES 

DISTRIBUTION. 

AREAS. 

^NECK  ANO  6CALP 


NECK  AND 
SHOULDER. 


SHOULOER.- 
>AflM. 


•LADDER  AND  RtCTUW 


HAN[>. ]    / 


.FRONT  OF 

'thorax. 


EPIGASTRIC. 


;ENSIF0RM  AREA. 


^ABDOMEN.  I 

JMBILICUS  (IOTm)J 


,'ABDOMISAL. 


CREMASTERIC. 


ANTERIOR  ASPECT  OP 
TMIOM  BELOW  SECOND 
LUHBAR  ROOT. 


BACK  or  THIGH,  exec* 

OtSTRIBUTION    OP 
1ST,  2n0  *  3R0  SACRAL 


I    NARROW    STRIP   ON 
I  SACK  or  THIGH.  LEO 
>ANO  ANHLE,    SOLI. 
I  PART  OP  DORtVH  OP 
I   POOT. 


FOOT  CLONUS. 


PtRIN«u«,  E«T.  OfN 
TALS,  SADOLC  SHAPED 
ARIA  or  tACA  OP  ThiOM. 


498  THE  SPINE. 

in  such  lesions  the  nerves  which  pass  out  lower  down  are  more  seri- 
ously involved  though  they  are  situated  nearer  the  center  and  would 
appear  to  be  less  exposed  to  pressure,  a  fact  that  is  not  explained. 

According  to  Starr  the  control  of  the  bladder  and  rectum  is  always 
lost  tor/ether.  It  is  lost  if  the  lower  three  sacral  segments  are  involved, 
and  the  control  centers  probably  lie  in  the  lower  two  of  these.  In  a 
lesion  involring  these  reflex  centers  absolute  incontinence  follows  tempo- 
rary retention,  the  bladder  first  distends  and  then  dribbles  from  over- 
distension. In  a  lesion  above  these  centers  the  cerebral  inhibitory 
control  is  cut  off  so  that,  after  a  temporary  retention  dne  to  shock,  the 
bladder  and  rectum  are  emptied  at  frequent  intervals  unconsciously 
and  involuntarily.  The  reflex  mechanism  being  intact  works  like  a 
clock  without  a  pendulum.  Similarly  in  lesions  above  the  r^/?e.r  center 
of  erection  of  the  penis,  which  is  in  the  same  part  of  the  lumbar  en- 
largement, the  inliibitory  fibers  are  cut  off  and  a  chronic  erection 
(priapism)  usually  occurs. 

Thorburn  has  called  attention  to  the  jxithognomonic  posture  assumed 
in  lesions  below  the  fifth  cervical  sef/menf  and  the  explanation  of  it.  The 
arms  are  abducted  by  the  deltoid,  and  rotated  out  by  the  supra-  and 
infra-spinati,  the  elbows  are  flexed  by  the  brachialis,  brachio-radialis 
and  biceps  and  the  hand  is  supinated  by  the  latter,  all  the  other 
muscles  of  the  arm  being  paralyzed.  As  the  phrenic  nerve  is  derived 
principally  from  the  f)urth  cervical  segment,  receiving  contributions 
from  the  third  and  fifth  segments,  lesions  at  or  above  this  level 
are  rapidly  fatal  from  failure  of  respiration.  In  lesions  between  this 
and  the  upper  thoracic  segments  the  respiration  is  entirely  diaphrag- 
matic. 

The  integrity  of  the  spinal  reflexes  depends  upon  that  of  the  afferent 
sensory  nerve,  the  efferent  motor  nerve,  their  connection  in  the  gray 
matter  of  the  cord,  and  the  inhibitory  fibers,  descending  in  the  antero- 
lateral columns,  by  which  the  brain  regulates  the  reflexes.  If  the  latter 
fibers  are  destroyed  by  a  lesion  all  reflexes  below  this  point  are  exag- 
gerated from  the  loss  of  cerebral  control.  If  the  afferent  or  efferent 
nerves  or  their  association  in  the  gray  matter  is  destroyed  the  reflex  is 
lost.  The  reflexes,  with  the  segments  to  which  they  correspond  clinic- 
ally, are  given  in  column  F  of  Fig.  125. 

Hemorrhage  may  occur  within  the  cord  (hcematomyelia)  or  within  the 
membrane's  (hiematorrhachis).  The  latter  may  extend  the  length  of 
the  cord  or  gravitate  largely  to  the  lower  end,  and  ])roduces  no  very 
localized  symptoms.  According  to  Thorburn,  haematomyelia  is  not  at 
all  uncommon  and  occurs  principally  between  the  fourth  cervical  and 
the  first  thoracic  segments  (inclusive),  corresponding  to  the  cervical 
vertebme  from  the  fourth  to  the  seventh  inclusive.  This  is  the  summit 
of  the  cervical  curve,  where  an  acute  bend  of  the  neck  would  make 
itself  mainly  felt.  In  fact  the  cord  has  been  crushed  by  such  a  bend 
without  fracture,  and  with  only  temporary  diastasis.  The  symptoms 
produced  by  such  a  hemorrliage  depend  upon  (1)  a  comj^ressing  and  (2) 
a  destroying  lesion  ;  the  former  temporary  and  causing  paralysis,  anses- 


OPERATIONS   UPON  THE  CORD.  499 

thesia,  loss  of  control  of  the  reflexes  of  the  bladder,  iictum  and  penis, 
etc.,  the  latter  permanent  and  causing  atrophic  paralysis,  and  perhaps 
anaesthesia,  of  the  parts  supplied  by  some  of  the  roots  of  the  brachial 
plexus.  These,  /lemorr/KU/r.s  are  mosf  ncvcrr  in  the  nndr  of  the  curd  so 
that  the  more  peri[)heral  filx-rs,  whieh  emerge  near  the  lesion,  may  not 
be  affected  by  the  excentric  pressure,  while  the  more  central  fillers, 
which  emerge  lower  down,  arc  more  and  more  afTccted  ;  hence  the  area 
of  anaesthesia  is  ill  defined  and  may  be  far  below  the  seat  of  the  lesion. 
Some  doubt  is  thrown  on  the  correctness  of  this  exjilanation  Ijy  the 
fact,  stated  by  Horsley,  that  the  same  tendency  to  involve  the  lowest 
sensory  fibers  first  is  found  in  the  case  of  tumors,  whose  pressure  is 
concentric.  In  tumors  flie.  invasion  of  paralyniH  is  from  alx^ve  down- 
ward, or  the  reverse  of  that  of  anesthesia.  The  /V/z-o/vVc  sit  nation  for 
tumors  is  below  the  middle  of  the  cervical  region  and  at  the  upper 
and  lower  ends  of  the  thoracic  region. 

Operations  upon  the  cord,  in  addition  to  those  for  fracture-disloca- 
tions, are  not  infrequently  done  for  tumors,  or  inflammatory  dejxjsits, 
the  operator  being  guided  by  the  above  and  other  minor  point.s  of 
localization.  The  cord  is  first  exposed  by  a  laminectomy.  Such 
operations  have  been  very  successful  when  the  tumor  has  been  removed 
and  the  operation  was  not  too  long  deferred. 


INDEX. 


A  BDOMEN,  236 
A     axis  of  284 

hlooil  vessels  of,  342 
blows  on,  240,  252 
boumlaries  of,  236 
cavity  of,  284 

congenital  deforniities  of,  245,  252 
injuries  of,  252 
lymphatics  of,  249,  343 
muscles  of,  240 
operations  on,  253 
regions  of,  255 
shape  of,  236 
skin  of,  239 

snrftice  markings  of,  237 
topography  of,  256 
wounds  of,  252 
Abdominal  aneurism,  342 
aorta,  342 
ascites,  285 
cavity,  284 
ring,  external,  261 

internal,  262 
tumors,  301 
viscera,  290 

nerves  of,  343 
wall,  239 

abscess  of,  242 

anterior,  239 

aponeuroses  of,  243 

blows  on,  246,  252 

deformities  of,  245,  252 

fascia  of,  239,  240 

incisions  in,  250,  253 

lymphatics  of,  249 

muscles  of,  240 

nerves  of,  250 

reflexes  of,  251 

posterior,  274 

subperitoneal  tissue  of,  247 

vessels  of,  248 

woimds  of,  252,  284 
Abscess,  alveolar,  100 
axillary,   lti8 
cervical,  143 
gluteal,  428 
iliac,  2(19.  275 
in  abdominal  wall,  242 
in  antrum.  5(1,  81 
in  mastoid,  5() 
in  slioath  of  rectus.  213 
in  tlie  scalp,  23 
in  tiie  testis,  413 
in  temporal  fossa,  24 
intercostal,  20(> 
ischio-rectal,  425 
lumbar,  281 


Abscess,  mammary,  210 

mediastinal,  204 

of  liip  joint,  438 

of  liver,  323 

orbital,  72 

palmar,  190 

parotid,  89,  90 

pelvic,  275,  357,  390 

perincpbritic,  282,  335,  336 

perityphlitic,  275 

plantar,  475 

popliteal,  451 

prostat  i  c,  36 1  -37  5 

psoas,  269-278 

renal,  335 

retrf)pliaryngeal,  114,  143 

spinal.  486 
Accommodation,  70 
Acetabulum,  348,  427,  434,  435 
Acromion  j)rocess,  147 

fractures  of,  156 
Acromio-clavicular  joint,  154 
dislocation  of,  154 
movements  of,  154 

-thoracic  arterv,  149 
Adductor  longus,  430,  432,  446,  447 

magnus,  447 

tubercle,  449 
Adenoids,  116 
Adrenals,  341 

relations  of,  341 
Air  in  veins,  129,  144 
Alderman's  nerve,  50 
Alveolar  abscess,  100 
Ampulla  of  Vater,  328 
Amputation  (see  special  part) 
Anal  fascia,  357,  422,  424 

triangle,  424 
Anastomoses  about  elbow,  177 

of  vessels  of  abdomen,  249,  342 
Aneurism  (si-e  speiial  arterj- ) 
Angular  curvature  of  sj»ine,  486 
Ankle,  465 

fasciie  of,  466—468 

joint,  4()8 

dislocations  of,  4«t9 
elVusions  into.  468,  400 
excision  of,  472 
fractures  about.  470 
lateral  motion  in,  469 
sjir.iins  of,  469,  471 

surface  markings  of,  465 

tendons  about,  4(>6 
sheaths  of,  467 

ItoiMigrapbv  of,  4t>6 
Ankvlosis  of  hip,  2S0,  486 
jaw,  98 
501 


502 


ISBEX. 


Annular  ligaments  of  ankle,  467 

of  wrist,  188 
Anteflexion  of  uterus,  382 
Anterior  crural  nerve,  432 

paralysis  of,  482 
tibial  artery,  461,  463,  465,  473 
Anteversion  of  uterus,  382 
Antrum  of  Highmore,  81 

empyema  of,  81 
relations  of,  82 
tumors  of,  82 
mastoid,  54  (see  mastoid  antrum) 
Anus,  364,  425 
artificial,  305 
development  of,  364 
epithelioma  of,  362 
fissure  of,  364 
imperforate,  364 
Aorta,  abdominal,  342 
arch  of,  229 
relations  of,  229 
thoracic,  230 
variations  of,  230 
Aortic  aneurism,  228-230,  342 
orifice,  226 
plexus,  343 
Apex  beat,  226 
Aphasia,  42 

Aponeuroses,  abdominal,  243 
Appendices  epiploic*,  315 
Appendicitis,  311,  312 
Appendiculo-ovarian  ligament,  311 
Appendix   vermiformis,   309   (see    vermi- 
form) 
Aqueduct  of  Fallopius,  53 
Arachnoid,  38 
Arches  of  foot,  476 
Argvll-Robertson  pupil,  TO 
Arm,  170 

amputation  of,  174 
fascia  of,  171 
nerves  of,  171,  172 
skin  of,  171 

surface  markings  of,  170 
topography  of,   171 
Arnold's  nerve,  50 
Arteries,  see  special  artery 
Arterio-venous  aneurism,  38 
Aryteno-epiglottic  folds,  132-134 
Arvtenoid  cartilages,  133,  134 
Ascites,  285,  324 
Asterion,  26 
Asthma,  221 

Astragalus,  469,  476-478 
dislocations  of,  479 
fracture  of,  481 
Atlas,  114,  484 
Auditory  meatus,  external,  47 

relations  of,  50 
Auricle,  left,  225,  226 

right,  22.5-227 
Auricles,  supernumerary,  47,  146 
Auriculo-temporal  nerve,  90 
Auriculo-ventricular  groove,  226 
Axilla,  148,  167 

boundaries  of,  167 


Axilla,  contents  of,  168 

suspensory  ligament  of,  155 
Axillary  abscess,  168 

aneurism,  169 

artery,  148,  155,  164,  167,  168 
course  of,  149 

fascia,  168 

line,  203 

Ivmph  nodes.  149,  169,  170 

Vein,  155,  164,  168,  169 
Azygos  major  vein,  222,  231 

BASE  of  skull,  fracture  of,  31 
Basilic  vein,  172 
Biceps,  grooves  along,  170 

cubiti  tendon,  159-161,  174,  175,  178 

dislocation  of,  161 
femoris  tendon  in  ham,  450,  452 
tenotomv  of,  452 
Bichat's  lobule,  88 
Bicipital  fascia,  174-176 
Bile-duct,  common,  course  of,  299,  328 
i  obstruction  of,  329 

i  operations  on,  328 

'  relations  of,   288,    298,    299, 

328 
Bladder,  365 

capacity  of,  365 
development  of,  372 
I  distension  of,  366,  498 

'  double,  369 

extroversion  of,  252 
fasciculated,  369 
female,  372 
fixation  of,  368 
hernia  of,  369 
interior  of,  371 
ligaments  of,  356,  368 
malformations  of,  373 
mucous  membrane  of,  369 
nerves  of,  370,  498 
new  growths  of,  373 
of  child,  372 
outlet  of,  366 
position  of,  365 
puncture  of,  360,  367 
relations  of,  359,  360 
relation  of  to  peritoneum,  366 
rupture  of,  368 
sacculated,  369 
shape  of,  365 

sphincter  of,  368,  375,  421 
structure  of,  369 
vessels  of,  370 
wall  of,  369 
wounds  of,  368 
Blepharo-spasm,  60 
Blood  vessels  of  abdomen,  342 
abdominal  wall,  248 
arm,  172 
brain,  40 
breast,  211 
buttock,  427 
elbow,  175-6 
face,  83 
foot,  473-4 


INDEX. 


503 


Blood  vessels  of  forearm,  184 

hand,  197 

knee,  450,  452,  453 

leg,  4G1-463 

neck,  121,  122,  125-129 

nose,  79 

orbit,  71 

palate,  108,  110 

pelvis,  357 

rectum,  302 

scalp,  20,  21 

.Scarpa's  triangle,  431-433 

shoulder,  155-168 

spermatic  cord,  416,  417 

thigh,  447 

tympanic  membrane,  52 
Bow  legs,  465 
Bi-achial  artery,  170,  172,  175 

abnormalities  of,  172 

aneurism  of,  176 

compression  of,  172,  176 

in  phlebotomy,  176 

ligature  of,  172 

line  of,  170 
fascia,  171 

plexus,  122,  123,  151,  152,  200 
Brachialis,  178 
Brachio-cephalic  artery,  231 

vein,  229,  230,  231 
radialis,  171,  173,  184,  186 
Brain,  39 

blood  supply  of,  40 

center  of  sensations  of  sound,  42 

of  taste  and  smell,  42 
compression  of,  40 
concussion  of,  40 
contusion  of,  40 
cortical  centers  of,  40 
fissures  of,  44 

functions,  locjilization  of,  40 
injuries  of,  40 
membranes  of,  33 
motor  area  of,  40 

mental  or  association  centers  of,  43 
relations  of,  to  skull,  43 
sensory  cortical  area  of,  42 
speech  areas  of,  42 
visual  center  of,  40 
Branchial  arches,  145 
clefts,  145 
listuhe,  145 
Branchiogenic  cysts,  146 
Brasdor's  operation,  127 
Breast,  208 

abscess  of,  210 
arteries  of,  211 
cancer  of,  lii'.t,  211 
capsule  of,  208 
lymphatics  of,  169,  211 
nerves  of,  21 1 
removal  of,  211 
Bregma,  26 
Broad  iigimient,  389 

borders  of,  390 

contents  of,  390 

relations  of,  390-393 


Bronchi,  221-223,  228,  22t) 

foreign  bodies  in,  222,  223 
Bronchial  lynijih  nodes,  223 
Bronchiectahis,  221 
Bronchocele,  138,  141 
Brunner's  glands  in  burns,  299 
Brvant's  line  and  triangle,  427 
Bubonocele,  263 
Buccal  nerve,  86 
Buccinator.  K6,  87,  88 
Bulb,  artery  of,  420,  422 

of  corpus  spongiosum,  408,  420,  422, 
423 
Bulbi  vestibuli,  394,  397 
Bulbous  portion  of  urethra,  400 
Bunion,  475 

Bursic  about  the  ankle,  468 
elbow,  177 
ham,  453 
knee  joint,  451 
shoulder,  158,  159 
over  the  great  trochanter,  429 
tuber  ischii,  345,  429 
prepatellar,  451 
subacromial,  158 
thyro-hyoid,  131 
Bursting  fractures  of  skull,  31,  32 
Buttocks,  426 

fa-scia  of,  428 
fold  of,  426 
nerves  of,  427 
surface  markings  of,  426 
topfigraphy  of,  427 
[  vessels  of,  427 

p  J^CUM,  306 
\j     foreign  bodies  in,  307 
forms  of,  306 
liernia  of,  307 

in  intestinal  obstruction,  308 
I  position  of,  307 

Calcaneo-astragaloid  joint,  479 

-scaphoid  ligament,  inferior.  476,  477 
,  Calcanemn,  467,  469,  472,  478,  481 
j  fracture  of,  481 

I  Canal  of  Nuck,  391 
C'analiculi,  63 
Cancrum  oris,  84 
Capsule  of  Glisson,  323 

of  Tenon,  66 
Cardiac  flatness,  area  of,  225 
incisure,  218,  225 
orifice  of  stomach,  291 
Carotid  artery,  common,  126,  231 
aneurism  of,  126 
ligature  of,  127 
line  of.  126 
relations  of,  127,  231 
wounds  of,  132 
external,  90,  128 

in  operations  on  tonsil,  112 
ligature  of,  128 
internal,  37,  12*.* 

in  operations  on  tonsil,  112 
sheath,  128 
triangles,  126 


504 


INDEX. 


Carotid  tubercle,  127,  484 
Caruncle,  lachrymal,  62 

urethral,  396 
Castration,  410,  416,  417 
Catheterization  of  Eustachian  tube,  58 
of  uretei's,  393 
of  urethra,  400,  405 
Cauda  equina,  494,  496 
Cava,  inferior,  322,  328,  332,  334,  340 

superior,  222,  228,  229,  231 
Cavernous  sinus,  37,  62 
Cavum  Retzii,  248,  367 
Cephalluematonia,  30 
Cephalic  vein,  148,  155,  170 
Cephaloceles,  27 
Cerebellum,  43 
Cerebral  localization,  40 
Cerebro-spinal   fluid,    31,    32,    427,    48 

489,  492 
Cervical  abscess,  143 
fascia,  deep,  141 
lymph  nodes,  144 
nerves,  119,  120 
ribs,  122 
sympathetic,  129 
triangle,  anterior,  123 

posterior,  120 
vertebne,  484,  488,  489,  490,  498 
Cervix  uteri,  381 

canal  of,  383 
elongation  of,  381 
external  os  of,  381 
relation  to  ureters,  382 
zones  of,  381,  382 
Cheeks,  83 
Chest  (see  Thorax). 
Cholecystectomy,  326 
Cholecystenterostomy,  317,  326 
Cholecystotomy,  326 
Choledocotomy,  328 
Chopart's  amputation,  480 
Chorda  tympani  nerve,  52,  53,  84,  106 
Chordee,  408 
Circle  of  Willis,  127 
Circumflex,  arteries,  149 

nerve,  149,  158,  164,  166 
Circumscision,  406 
Cirrhosis  of  liver,  324 
Cirsoid  aneurism,  21 
Clavicle,  147 

dislocations  of,  152 
excision  of,  152 
fractures  of,  149 
periosteum  of,  151 
relations  of,  151 
Clavipectoral  fascia,  155,  167 
Cleft  palate,  110 
Clitoris,  397 
Club-foot,  477 
Coccydynia,  346 
Coccygeus,  354,  357,  424 
Coccyx,  427 

excision  of,  365 
fracture  of,  346 
tip  of,  346 
Cocks  operation,  361 


Cceliac  axis,  342 

plexus,  231,  343 
Colles'  fracture,  191 
Colon,  314 

ascending,  316 
capacity  of,  314 
characterized  by,  314 
descending,  316 
diverticula  of,  315 
hepatic  flexure  of,  317 
mesentery  of,  316 
sigmoid,  317 
splenic  flexure  of,  317 
mesentery  of,  318 
stricture  of,  314 
transverse,  287,  316 
tube,  318 
Colotomy,  inguinal,  318,  319 

lumbar,  316,  318 
Compression  fractures  of  skull,  31,  32 
of  brain,  40 
of  cord,  491-493 
Compressor  urethra?,  399,  421 
Concussion  of  brain,  40 

of  cord,  493 
Condylar  vein,  posterior,  37 
Condyles  of  femur,  449,  454,  457 
of  humerus,  175 

fractures  of,  181,  182 
Congenital  club-foot,  478 
dislocation  of  hip,  441 
liernia,  264 
hydrocele,  414 
malformations  of  anus,  364 
of  bladder,  252 
of  penis,  409 
torticollis,  119 
Conjoined  tendon,  241,  262 
Conjunctiva,  (il 

Constrictors  of  pliarynx,  116,  117 
Contre-coup,  fracture  by,  32 
contusion  due  to,  40 
Convolutions  of  brain,  centers  of,  40 
Coraco-acromial  arch,  160 

ligament,  148,  166 
Coraco-bracliialis,  169 
Coracoid  process,  148 

fractures  of,  156 
Cord,  spermatic,  202,  271 

hydrocele  of,  264,  414 
spinal,  491 

compression  of,  491,  493 
concussion  of,  493 
Cords,  vocal,  133 
Coronal  suture,  26,  47 
Coronary  arteries,  98 
Coronoid  ])rocess  of  jaw,  95,  97,  100 

of  ulna,  179,  183 
Corpus  cavernosum,  408 
luteum,    386 
spongiosum,  408 
striatum,  function  of,  43 
Costal  cartilages,  204,  237 
Costo-coracoid  memljrane,  155 

-mediastinal  sinus,  215 
Costophrenic  sinus,  213,  216 


ISDEX. 


.505 


•Cotyloid  ligament,  436,  444 
Cowper's  glands,  399,  420,  421 
Coxa  vara,  444 
Coxitis,  437 
Craniectomy,  18,  26 
Cranio-cerebral  top()gra[)liy,  43 

-tabes,  27 
Cranium,  bony  landmarks  of,  25 
Creases  of  palm,  193 

of  wrist,  187,  ISK 
Cremaster  nmscle,  262,  411 
Cremasteric  arterv,  411 

fascia,  262,  410 

reflex,  411,  434 
Cretinism,  140 
Cribriform  fascia,  272,  431,  432 

l)late,  73,  70,  79 
Cricoid  cartilage,  118 

fracture  of,  135 
Crico-thyroid  membrane,  135 
Crura,  lesions  of,  43 
Crural  arches,  247,  269,  271 

canal,  270 

nerve,  anterior,  432 

ring,  270,  431 

sheath,  247,  270 
Crutch  paralysis,  173 
Cubital  fossa,  174 
Cuboid  bone,  472 
Cuneiform  bones,  479-480 
Curvature  of  spine,  202,  485,  487 
Curves  of  spine,  484 
Cut-throat  wounds,  131 
Cystic  duct,  327 
Cystotoniy,  jjcrineal,  422,  423 

suprapubic,  359,  367 
Cysts,  dermoid,  59,  347,  387 

DARTOS,  3il7,  406,  410 
I)eg]utition,  109,  117 
Deltoid  muscle,  157,  158,  162,  166,  170 

region,  157 

tubercle,  147 

nerve,  86 
Dentition,  101 
Dcscendens  noni,  128 
Descending  palatine  artery,  108,  110 
Diaphragm,  212 

level  of,  213 

malformation  of,  212 

openings  in,  213 

wounds  of,  213 
Diaphragmatic  hernia,  212 
Digastric  muscle,  12.3 
Diploi',  veins  of,  22 
Dipl()i)ia,  68,  70 
Direct  inguinal  hernia,  266 
Dislocations,  see  several  bones  and  ji)int< 
Dorsal  vein  of  penis,  35(),  403,  407,  422 
Dorsalis  ja'dis  artery,  466,  468,  473 

scapular  artery,  157 
Douglas,  curvc<l  line  of,  245 

])ouch  (.f,  3(;o,  380,  393 
Drop  wrist,  173 
Duct,  of  Miiller,  385 

of  San  tori  ni,  333 


Duct,  thoracic,  229,  230 
Duodenal  fossa,  300 

papilla,  299,  328 

ulcer,  299 
Duodenum,  297 

crescent ic  fold  of,  299 

])osition  of,  297-299 

relations  of,  298,  299 
Dupuvtren's  contracture,  195 
Dura,'  33 

arteries  of,  34 

at  base  of  skull,  35 

of  cord,  491 

outer  layer,  adhesion  of  to  l>onc,  34 

processes  of,  36 

sinuses  of,  36 

mechanism  to  prevent  aspiration 
of,  38 

tj'AR,  47 
J     bleeding  from  in  fractureofba.se,  33 

coughing,  50 

dcveloimient  of,  17 

external,  47 

foreign  bodies  in,  49 

frost  bite  of,  47 

haMnatomata  of,  47 

lymphatics  of,  58 

middle,  52 

nerves  of,  50 

sneezing,  50 

specula,  48 

watery  discharge  from,  33 

yawning,  50 
Ectroj)ion,  59,  63 
Ejaculatorv  ducts,  .".76,  .399 
Elbow,  174 

bursa  behind,  177 

dislocations  of,  178 

excision  of,  178 

fold  of,  174 

fractures  about,  181 

joint,  177 

effusions  into,  177 

region,  174 

surf:icc  markings  of,  174 

topograjjhy  of.  174 
Elephantiasis,  412,  4.34 
Emissary  veins  of  skull,  21 
Emphysema,  221 

subcutaneous,  217,  222 
I^nipyema,  206 
Encephahjcele.  27 
Encysted  hydrocele  (>f  the  cord,  264 
Ensiforin  cartilage,  204,  237 
I'nterotomy,  ."05 
llnirojiioii,  60,  61,  63 
lOpididymis,  414 

glol>us  major  of,  414 
minor  of,  415 
Epididymitis,  415 
Epigastric  region,  25(> 

vein,  superficial,  239,  249 

ve.-^sels,  deep,  245,  248,  262,  2(53,  266, 
271 
Epiglottis,  lis,  l.'.l.  1 :'..!,  135 


506 


INDEX. 


Epilepsy,  cervical  sympathetic  in,  130 
Epiphysis  of  acetabulum,  435 

of  acromion,  separation  of,  156 
of  femur,  449 

lower,  in  excision  of  knee,  459 
in  knock  knee,  454 
separation  of,  460 
upper,  separation  of,  438,  444 
of  fibula,  472 

of  humerus,  separation  of,  165,  182 
of  radius,  192 

of  third  phahmx,  in  whitlow,  199 
of  tibia,  459,  472 
Epipteric  bone,  27 
Epispadias,  409 
Epistaxis,  79 
Episternal  notch,  118 
Epitrochlear  node,  177 
Epulis,  95,  101 
Erector  spina",  279,  281 
Eruption  of  teeth,  101 
Estlander's  operation,  206 
Eustachian  tube,  56 

catheterization  of,  58 
direction  of,  56 
in  infants,  57 
obstruction  of,  57 
pharyngeal  orifice  of,  57 
Excision  (see  special  parts) 
Exophthalmic  goiter,  cervical  sympathetic 

in,  130,  141 
External  abdominal  ring,  261 

angular  process  of  frontal  bone,  25,  59 
auditory  meatus,  47 

abscess  of,  49 

cartilaginous  portion  of,  49 
diameters  of,  48 
direction  of,  48 
nerve  supply  of,  50 
relations  of,  50 
skin  of,  49 
carotid  artery,  90 

in  operations  on  tonsil,  112 
cutaneous  nerve,  172,  176 
iliac  artery,  275-6 

lymph  nodes,  277 
mammary  artery,  149,  211 
oblique  muscle,  239,  241 
spermatic  fascia,  240,  261 
Extravasation  of  urine,  240,  407,  420 
Extroversion  of  bladder,  252,  373 
Ej'eball,  enucleation  of,  67,  68 
Ej-ebrows,  59 
Eyelids,  59 

arteries  of,  62 
canthi  of,  61,  62 
epithelioma  of,  59 
foreign  bodies  beneath,  62 
free  borders  of,  ()2 
layers  of,  59 
cedema  of,  60 
skin  of,  59 

FACE,  59,  82 
development  of,  99,  110 
nerves  of,  84 


Face,  skin  of,  83 

Facial  arterv,  83,  112,  124 

nerve,  o9,  60,  84,  90,  108 

paralvsis,  53,  84,  85 

vein, '83,  124 
Ffecal  concretions,  308,  312 

impaction,  308 
Fallopian  tube,  388 

course  of,  388 

fimbriated  extremity  of,  388 

nuicosa  of,  388-9 

operation  on,  389 
Fascia,  abdominal,  239-40 

axilhiry,  168 

bicipital,  174-176 

cervical,  141 

clavi-pectoral,  155-167 

iliac,  269,  270,  277 

lata,  271,  446 

lumljar,  280 

obturator,  356,  422,  424 

of  ankle,  466-468 

of  arm,  171 

of  buttocks,  428 

of  deltoid  region,  157 

of  foot,  467,  474,  477,  478 

of  leg,  462 

of  palm,  195 

of  penis,  407 

of  scalp,  20 

of  thigh,  446 

orbital,  66 

palmar,  195 

parotid,  88 

pectoral,  155,  167,  210 

pelvic,  356 

perineal,  419 

plantar,  467,  474,  477,  478 

popliteal,  451 

prevertebral,  142 

recto-vesical,  356,  369,  422 

temporal,  24 

transversalis,  245,  246,  262 
Fasciculated  bladder,  369 
Fauces,  isthmus  of,  109 

pillars  of,  109 
Felon,  199 
Femoral  aneurism,  433 

arch,  247,  269,  271 

artery,  431,  432,  440,  446,  448 
compression  of,  432,  447 
ligation  of,  433,  447 
line  of,  431 

canal,  270 

hernia,  272 

ring,  270,  431 

sheath,  247,  270 

veins,  270,  431,  447,  448 
ligature,  of,  433 
wound  of,  433 
Femur,  condyles  of,  449,  454,  457 

dislocation  of,  438 

fracture  of,  447,  460 

epiphyses  of,  438,  444,  449,  454,  459 

excision  of,  444,  459 

head  of,  427,  430,  434,  439,  440 


IXDEX. 


507 


Femur,  neck  of,  angle  of,  441 
fracture  of,  442 
fracture  at  base  of,  442 
osteoporosis  of,  441 

trochlear  surface  of,  449,  4.>"),  4')7 
Fenestra  ovalis,  o8 

rotunda,  o-'! 
Fibula,  4()1 

fractures  of,  4C)4,  470-472 

head  of,  44it,  4()0 
Fifth  nerve,  70,  85 

section  of  (see  branches) 
Fimbria  ovarica,  38(5,  888 
Finger,  cutaneous  nerve  supply  of,  198 

dislocation  of,  199 
Fibrous  sheaths  of  flexor  tendons,  190 
Fissure  of  anus,  3(34 
Fissure  of  Rolando,  44 

of  Sylvius,  4-"> 

parieto-occipital,  4() 
Fissures  of  brain,  localization  of,  44 

of  Santorini,  49 
Fistula,  branchial,  145 

in  ano,  3()4,  425 

lachrymal,  G4 

salivary,  87 

umbilical,  259 

vesico-vaginal,  372-393 
Flat-foot,  474,  477,  478 
Fold  of  buttock,  426 

of  elbow,  174 
Fontanelles,  2G 
Foot,  472 

abscess  of,  475 

amputations  of,  480,  481 

arches  of,  474,  476 

longitudinal,  476,  477 

maintained  by,  476 
transverse,  476 

maintained  by,  476 

blood  vessels  of,  473,  474 

dislocations  of,  469,  479,  480 

fasciae  of,  474 

fractures  of,  481 

joints  of,  479 

lymphatics  of,  475 

nerves  of,  475 

surface  markings  of,  472 

synovial  membranes  of,  480 

topography  of,  473 

veins  of,  474 
Foramen  ca'cura  (of  tongue),  104 

of  Majendie,  39,  492 

of  AVinslow,  288,  289,  298,  328,341 
Forearm,  183 

amputation  of,  186 

bones  of,  185 

dislocations  of,  179,  180 

fractures  of,  185 

landmarks  of,  183 

surface  markings  of,  183 

vessels  of,  184 
Foreign  body  in  air  passages,  133,  138 
in  ear,  49 
in  a'soj)hagus,  234 
Fossa,  duodeno-jejunal,  300 


Fossa,  ileo-cffcal,  313 
-colic,  313 
infraclavicular,   148 
inguinal,  263 
intersigmoid,  31 H 
ischio-rectal,  361,  422,  424 
nasal,  75 
navicularis,  400 
of  Kosenmiiller,  5>i,  IM 
subcecal,  314 
supraclavicular,  120 
Fourchette,  397 
Fourth  nerve,  70 
Fracture  (see  several  Ijones) 

dislocation  of  vertebra-,  489,  490,  491, 
493 
Frenum  lingua;,  103 

preputii,  408 
Frontal  artery,  21 
sinuses,  80 

empyema  of,  81 
fracture  of,  81 
operations  on,  81 
Fundus  of  stomach,  291 
Funicular  process,  hernia  into,  265 

GAEKTXER.  duct  of,  387 
Gall-bladder,  32-') 

empyema  of,  326 
lymphatics  of,  326 
operations  on,  326 
position  of,  325 
relations  of,  326 
stones,  326 
Gasserian  ganglion,  38 
removal  of,  38 
Gastrectasia,  292 
Gastric  ulcer,  296 
Gastrocnemius,  450,  461 
Gastro-colic  ligament,  287,  298,  317,  332 

-enterostoniv,  293 
Gastroptosis,  292 
Gastro-splenic  omentum,  330 
Gastrostomy,  293 
GiLstrotomy,  293 
Genital  organs,  female,  379,  397 

male,  373,  398 
Geni to-crural  furrows,  345 

nerve,  411,  417,  434 
Genu  valgum,  454 

Gimbernat's  ligament,  244,  269,  271,  273 
Glabella,  25 
(ilans  penis,  408 

Glaucoma,  cervical  sympathetic  in,  130 
Glenoid  cavity.  14S,  'l(il-163 
Glisson's  capsule,  323 
Glossitis,  1(12 

Glosso-pharvngeal  nerve,  106 
Glottis,  133' 

tt'dema  of  the,  134 
spasm  of  the,  133 
Gluteal  abscess,  428 
aneurism,  429 
artery,  355,   127.  429 

ligat\ire  and  wounds  of,  429 
fascia,  428 


508 


INDEX. 


Gluteal  fold,  426 

muscles,  418,  425,  428 

nerves,  427 

region,  426 
Gluteus  maximus,  418,  425,  428,  429 

medius,  427,  428  429 
Goitre,  138,  141 
(jreat  auricular  nerve,  120 
Groin,  fold  of,  238,  239 
Gubernaculum  testis,  412 
Gullet  (see  oesophagus) 
Gums,  100 
Gustatory  nerve,  106 

operations  on,  106 

H HEMATOCELE,    357,    387,    391,    393, 
397,  414 
Haeraatomata  of  scalp,  23 

of  ear,  47 
Hffimatomyelia,  493,  498 
Hiemorrhage  froui  frenum  lingua>,  104 
intercostal  vessels,  206 
internal  mammary,  207 
operations  on  tongue,  104,  105 
tonsil,  112,  113 

in  amputation  at  hip  joint,  445 
slioulder  joint,  167 

in  lithotomy,  422,  423 

in  tracheotomy,  138 

meningeal,  34 
Ha^morrhoidal  artery,  external,  424,  425 
superior,  358,  362 

veins,  362 
Haemorrhoids,  363 
Hfemothorax,  218 
Hallux  valgus,  475 
Hammer  toe,  482 
Hamstring  muscles,  447,  452 

tendons,  contracture  of,  452 
rupture  of,  452 
Hamular  process,  109 
Hand,  193 

cutaneous  nerve  supply  of,  198 

extensor  tendons  of,  198 

fasciae  of,  195 

landmarks  of,  193 

motor  nerve  supply  of,  198 

surface  markings  of,  193 

synovial  sheaths  of,  196 

vessels  of,  197 
Hard  palate,  107 
Harelip,  99 

operation  on,  100 
Head,  17 

general  considerations,  17 

natural  position  of,  17 

asvmmetrv  of,  17 
Heart,"  225 

apex  of,  226 

arteries  of,  227 

displacements  of,  226 

orifices  of,  226 

physical  examination  of,  225 

posit itm  of,  225 

relation  to  surface,  226 

surfaces  of,  225 


Heart,  topography  of,  226 

wounds  of,  227 
Hepatic  abscess,  317 
arterv,  288,  324 
colic"  329 
duct,  327 
flexure,  317 
Hepato-colic  ligament,  317 

duodenal  ligament,  288,  297,  299 
Hermapliroditism,  409,  412 
Hernia,  acquired,  external  inguinal,  165 
congenital  inguinal,  264 
diaphragmatic,  212 
direct  inguinal,  266 
external  inguinal,  263 
femoral,  272 
indirect  inguinal,  263 
infantile  inguinal,  265 
inguinal,  263,  397 

in  tlie  female,  268 
internal  inguinal,  266 
interstitial^  268 
into  the  funicular  process,  265 
ischiatic,  355 
ischio-rectal,  356 
lumbar,  280 
mesenteric,  289 
oblique  inguinal,  263 
obturator,  355 
omental,  287 
perineal,  356 
properitoneal,  248 
pudendal,  397 
sigmoid,  318 
umbilical,  257-259 
vaginal,  356 
Herniotomy,  267,  273 
Herpes  zoster,  251 
Hesselbach's  triangle,  263 
Heys'  amputation,  480 
Hiatus  diaphragmaticus,  212,  334 
Hip,  dislocations  of,  438 

dorsal  forms  of,  439 
forward  forms  of,  440 
reduction  of,  440 
joint,  434 

amputation  at,  444,  445 

control  of  hemorrhage  in,  445 
incisions  for,  445 
vessels  divided  in,  445 
congenital  dislocation  of,  441 
disease  of,  426,  437,  438,  486 
cflusion  into,  437 
excision  of,  444 
movements  of,  436,  437 
strongest  part  of,  435 
weakest  part  of,  435 
fractures  al)out,  441-443 
region  of,  426 
topography  of,  434 
Housemaid's  knee,  451 
Houston's  folds  of  rectum,  362 
Human  tails,  347 
Humerus,  148,  171 
condyles  of,  175 
dislocations  of,  160 


ISDEX. 


509 


Humerus,  epiphyses,  separation  of,  105,  182 

fractures  of,  1(34-106,  173 
non  union  after,  173 

head  of,  148 

great  tuberosity  of,  148,  101 
JIunler's  canal,  447 
Hydatid  of  Morgagni,  ;)87,  410 
Hvdrencephalotcle,  27 
Hydrocele  in  the  female,  3!i2,  307,  414 

of  the  tunica  vaginalis,  411,  412,  414 

of  the  cord,  204,  414 
Hydrocephalus,  20 
Hydronephrosis,  340 
Hymen,  31i4 
Hyoid  bone,  117 

fractures  of,  130 
Hypertrophy  of  the  prostate,  373-375 
Hypochondriac  region,  250 
Hypogastric  artery  (ol)literated),  263,  368 
Hypogastric  region,  257 
Hypoglossal  nerve,  106,  125 
Hypospadias,  409 
Hypothenar  eminence,  193 
Hysterectomy,  385 

ICHTHYOSIS  of  tongue,  104 
1     Ileo-ciecal  intussusception,  309 
region,  300 
valve,  308 

competency  of,  308,  309 
Heo-colic,  artery,  313 

intussusception,  309 
Ileum,  300,  301 
limits  of,  302 
position  of,  300,  301 
Iliac  abscess,  209,  275 
artery,  common,  275 

ligature  of,  277 
external,  275 

ligature  of,  27*) 
line  of,  275 
relations  of,  276 
crest,  238 
fascia,  247,  277 
furrow,  238 
regions,  257,  274 
spine,  anterior  superior,  237,  352 
inferior.  434 
posterior  superior,  238,  427 
Ilio-femoral  band,  435,  439,  440,  444 
-hypogastric  nerve,  250 
-inguinal  nerve,  250 
-pectineal  line,  244,  348 
-psoas  muscle,  432,  444 

bursa,  432,  430 
-tibial  band,  428,  446,  449 
Hium,  279 

Imperforate  anus,  304 
Incontinence  of  feces,  498 

of  urine,  370,  49S 
Indirect  inguinal  hernia,  203 
Inequality  of  liml's  in  length,  448 
Infantile  inguinal  hernia,  205 
Inferior  carotid  triangle,  120 
dental  nerve,  80 

excision  of,  86 


Inferior  maxilla  (see  mandible) 

thyroid  veins,  130,  140 
Infraclavicular  fossa,  148 
Infraorbital  foramen,  85 
nerve,  00,  85 

excision  of,  85 
Infundibuliform  fascia,  247,  410,  411 
Infnndibnlo-pelvic  ligament,  38<i,  390 
Infuiiflibidum,  78 
Inguinal  canal,  2<iO,  202 
colotomv,  319 
fold,  238,  239 
fossje,  203 
hernia-,  203 
lymph  nodes,  200,  475 
region,  200 
Inguino-femoral  region,  209 
In ion,  25 

Innominate  artery,  231 
ligation  of,  231 
bone,  348 

vein,  left,  229,  230,  231 
right,  231 
Interarticular  libro-cartilage  of  jaw,  97 
Intercohmniar  fascia,  240,  261 
Intercostal  arteries,  206 
nerves,  200,  207 
spaces,  200 
Intercosto-huraeral  nerve,  208 
Intermaxillarv  bone,  99,  110,  111 

in  harelip,  99,  110, 
Internal  abdominal  ring,  262 
carotid  artery,  37,  129 

in  operations  on  tonsil,  112 
cutaneous  nerve,  172,  176 
jugular  vein,  129 
mammary  artery,  207 
obliciue  muscle,  241 
pudic  artery,  355,  356,  422,  425,  427 
saphenous   nerve,  433,  446-447,  450, 
459,  402 
vein,  431,  433,  446,  450,  459,  401, 
402,  404,  400,  474 
Interosseous  arteries,  187 

membrane,  185 
Interparietal  bone,  27 
Interscapulo-thoracic  amputation,  167 
Intersigmoid  fossa,  318 
Intervertebral  disc,  488 
Intestine,  large,  306  (see  colon,  ciecum  and 
rectum) 
resectit»n  of,  305 

small,  297  i  see  also  duodenum,  ileum 
and  jejunum) 
diverticula  of,  305 
injury  of,  305 
length  of,  297 

mesentery  of,  288 
lymphatics  of,  304 
operations  on,  .305 
position  of,  300,  301 
structure  of,  .302,  303 
vessels  oi,  3tH 
wall  of,  302,  303 
wounds  of,  303,  305 
Intestinal  suture,  306 


510 


INDEX. 


Intussusception,  305,  309 
Inversion  of  testis,  412,  415 
Ischiatic  hernia,  355 
Ischio-pubic  rami,  345 
-rectal  abscess,  425 

fossa,  361,  422,  424 

anterior  recess  of,  422,  424 
apex  of,  424 
boundaries  of,  424 
posterior  recess  of,  424 
hernia,  356 
Isthmus  of  thvroid,  136,  138,  139 

division  of,  136,  138,  139 

JAW   (see  mandible  and  superior  max- 
illa) 
Jejunum,  300 
limits  of,  302 
position  of,  300,  301 
Jejunostomy,  305 
Joints  (see  special  articulation) 
Jugular  vein,  anterior,  119 
external,  121 
internal,  129,  145 

KELOID,  frequent  seat  of,  204 
Kidney,  abnormalities  of,  337 

abscess  about,  282,  335,  336 

fatty  capsule  of,  336 

fibrous  capsule  of,  338 

fixation  of,  336 

floating,  336 

hilum  of,  334,  337 

horseshoe,  337 

movable,  336 

nerve  supply  of,  338 

operations  on,  338 

pelvis  of,  337 

position  of,  333,  334 

relations  of,  216,  298,  316,  334 
to  peritoneum,  335 

rupture  of,  336 

tumors  of,  335 

vessels  of,  337 

Avounds  of,  336 
Knee,  burs;e  about,  451 
coverings  of,  451 
fascia  of,  451 
fractures  about,  455,  460 
joint,  453 

amputations  through,  459 

arthrectomy  of,  459 

dislocations  of,  453 

effusion  into,  449,  455,  457,  459 

excision  of,  459 

interarticular  line  of,  449 

ligaments  of,  454 

loose  bodies  in,  458 

subcrural  bursa  of,  458 

synovial  membrane  of,  458 

synovitis  of,  459 
region  of,  449 
surface  markings  of,  449 
Knock  knee,  454 
Kraske's  operation,  365,  430 
Kyphosis,  202,  485 


LABIA  majora,  397 
minora,  397 
Lachrymal  abscess,  64 

apparatus,  63 

gland,  63 

groove,  64 

sac,  61,  64 

tumor,  64 
Lacuna  magna,  urethral,  401 
Lacuna^  of  Morgagni,  401 
Lambda,  26 
Lambdoid  suture,  26 
Laminectomy,  491 
Large   intestine   (see  csecum,   colon,   and 

rectum ) 
Laryngeal  nerve,  superior,   106,  126,  131, 
133,  135 
_  inferior,  133,  135,  140,  229,  230 
Laryngismus,  stridulus,  133 
Laryngoscopic  image,  133 
Laryngotomy,  135 
Larynx,  132 

excision  of,  135 

foreign  bodies  in,  133 

fracture  of,  134 

mucosa  of,  134 

polypi  of,  134 

surface  markings  of,  118,  132 

topography  of,  132 
Lateral  curvature  of  spine,  202,  487 

ligaments  of  uterus,  380 

lithotomy,  422 

sinuses,  course  of,  36 
Latissimus  dorsi,  280 
Left  auricle,  225,  226 

ventricle,  225,  226,  228 
Leg,  460 

amputation  of,  465 

deep  transverse  fascia  of,  462,  463 

fasciie  of,  462 

fractures  of,  464,  470 

skin  of,  461 

surface  landmarks  of,  460 

vessels  of,  461,  463 
Lembert  sutures,  303 

Levator  ani,  354,  356,  359,   361,  374,  422, 
424 
relation  to  fistula  in  ano,  364 

palati,  108,  10!) 

palpebnc,  61,  70,  71 
Ligament  (see  special  joints,  etc.) 
Ligamentum  patella?,  449,  455 

subflavum,  489,  492 

teres,  435,  436,  444 
Lighterman's  bottom,  429 
Line,  axillary,  203 

mammary,  203 

scapular,  203 

sternal,  203 

white,  35(),  361,  424 
Linea  alba,  238,  245,  253 
hei'nia  of,  246 
incision  in,  253 

semilunaris,_  238,  244,  253 
incision  in,  253 
Linea>  transversa',  392,  242 


INDEX. 


511 


Lingual  artery,  125 

nerve,  lOG 

tonsil,  104 

triangle,  125 
Liponiata  in  deltoid  region,  157 

in  region  of  Scarpa's  triangle,  481 

on  the  buttock,  428 
Lips,  98 

development  of,  99 
Lisfranc's  amputation,  480 
Lithotomy  in  children,  423 

lateral,  422 

parts  divided  in,  422 
parts  to  be  avoided  in,  422 

median,  423 

versus  lateral,  423 

supi'apubic,  359,  3()7 
Littre's  operation,  319 
Liver,  319 

abscess  of,  323 

carcinoma  of,  325 

enlargements  of,  321 

fixation  of,  322 

general  considerations  of,  320 

limits  of,  320 

malposition  of,  322 

nerves  of,  325 

position  of,  ;)20 

relations  of,  298,  299,  322 

ruptures  of,  319,  322 

structure  of,  323 

surfaces  of,  322,  333 

wounds  of,  320,  322 
Localization,  cerebral,  40 
Lockjaw,  98 
Longitudinal  bands  of  large  intestine,  306, 

314 
Longitudinal  sinus,  superior,  36 
Lordosis,  351,  437,  480 

in  hip  disease,  280,  486 

cutaneous  nerve  supply  of,  482 
Lower  limb,  length  of,  448 

measurement  of,  352 
motor  nerve  supply  of,  482 
Ludwig's  angina,  107 
Lumbago,  283 
Lumbar,  abscess,  281 

colotomv,  318 

fascia,  280 

hernia,  280 

incisions,  282 

lymph  nodes,  343 

nerves,  242,  283 

puncture,  39,  280,  489,  492 

region,  257,  279 
wounds  of,  283 

spine,  488,  489,  490 

vertebra',  spines  of,  237,  279,  2S0,  345, 
484 

vessels,  282 
Lung,  218 

apex  of,  218,  220 

at  birth,  220 

base  of,  219 

bordei-sof,  218 

capacity  of,  220 


Lung,  cardiac  incisure  of,  218,  225 

elasticity  of,  221 

fissures  of,  219 

hernia  of,  122,  218 

in  neck,  21 S 

lobes  of,  219 

outline  of,  218 

jiosition  of,  218 

puncture  of,  220 

relations  of,  219 

root  of,  220,  222,  229 

vessels  of,  221 

wounds  of,  222 
Luschka's  tonsil,  58,  116 
Lymph  nofles  (see  each  region) 

vessels  (see  each  region) 

McBURNEY'S  point,  238,  312 
Macroglossia,  105 
Macrostoma,  100 
Maicudic,  foramen  of,  39,  492 
Malleoli,  4(15-467,  469,  472,  479 

fractures  of,  470-472,  479 
Malleus,  jjrocesses   of,   seen    through   ear 

drum,  52 
Mamma  (see  breast) 
Mammarv  line,  203 
Mandible,  94 

condyle  of,  90 
dislocation  of,  96 
excision  of,  95 
fracture  of,  94 
necrosis  of  92,  101 
tumors  of,  95,  102 
Margo  acutus,  225,  226 
Masseter,  86,  87,  95,  97 
Mastoid  antrum,  54 

development  of,  56 
infiammation  of,  56 
operation  on,  54 
passageway  into,  54 
position  of,  54 
relations  of,  55 

to  sigmoid  sinus,  56 
cells,  56 
region,  25 
vein,  .■'>7 
Masto-s(|Uamous  suture,  54 
Maxilla,  attaciiments  of,  92 
cleft  of,  110 
excision  of,  93 
fnicture  of,  92 
necrosis  of,  92 
tumors  of,  92,  94,  102 
Maxillary  sinus,  81 

empyema  of,  81 
relations  of,  81,  82 
tiimors  of,  82 
Meiu^urcnicnt  of  lower  limb,  352 

of  upper  limb,  147,  U)2 
Meatus,  external  auditory,  47 

internal  urinary,  366,  371,  403 
Meatuses  of  nose,  77,  78 
Meckel's  diverticulum,  257,  304 
ganglion,  82,  ^i^ 
excision  of,  85 


512 


ISDEX. 


Median  litliotomv,  423 

nerve,  171,  172,  188,  197,  198 

paralysis  of,  198 
vein,  176,' 188 
basilic  vein,  176 
cephalic  vein,  176 
Media.stinura,  abscess  of,  204 
Medio-carpal  joint,  190 
-tarsal  joint,  473,  480 

amputation  at,  480 
Medulla,  43 
Meibomian  glands,  63 
Membrana  tympani,  51 

otoscopic  image  of,  51 
rupture  of,  32 
Membranes  of  brain,  33 

spinal  cord,  427,  491,  492 
Membranous  urethra,  361,  399 
Meningeal  artery,  middle,  34 

hemorrhage  from,  31,  34 
operations  on,  35 
position  and  course  of,  35 
Meninges  of  brain,  33 

spinal  cord,  427,  491,  492 
Meningitis  from  otitis  media,  etc.,  53 

spinal,     from     carbuncle,     bedsores, 
etc.,  492 
Meningocele,  27 
spinal,  488 
Mental  foramen,  86 

nerve,  86 
Mesenteric  arteries,  342,  358 
hernia,  289 
plexuses,  343 
Mesenterv,  288 

holes  in,  289,  301 
length  of,  268,  288 
suspensory  muscle  of,  288,  300 
Mesenteriolum,  31U 

Meso-colon,  transverse,  289,  298,  299,  317 
-gastrium,  286 
-salpinx,  388,  390 
Metacarpal  bones,  fracture  of,  199 
Metacarjio-phalangeal  joint  of  thumb,  dis- 
location at,  199 
Metatarsal  bone,  fifth,  472 

fractures  of,  481 
Metatarso-phalangeal  joint,  473 
amputation  at,  481 
dislocation  at,  481 
Microcephalus,  18,  26 
Middle  meningeal  artery  (see  meningeal) 
Miner's  elbo\s',  177 
Mitral  orifice,  projection  of,  on  chest  wall, 

226 
Mons  veneris,  239,  345 
Morgagni,  columns,  valves  and  sinuses  of, 
262 
lacunse  of,  401 
hydatids  of,  387,  416 
Motor  centers  of  cortex,  40 
oculi,  61,  69 
paralysis  in  injuries  to  cord,  495,  496, 

498 
diaphragm  of,  102 
Mouth,  floor  of,  102 


Mucous  polvpi  of  nose,  79 
Mumps,  89-91 
Muscle  of  Horner,  63 
Muscular  compartment,  269 
Musculo-cutaneous  nerve,  171,  474 
Musculo-spiral  nerve,  171,  172 

paralysis  of,  173 
Mylohyoid  muscle,  102 
Myxcedema,  140 

XT  ARES,  anterior,  74 
li      plugging  of,  75 

posterior,  75 
Nasal  bones,  fracture  of,  73 

cartilages,  74 

douche,  80 

duct,  64,  65,  77 

fossae,  75 

lymphatics  of,  79 
mucosa  of,  78 
nerve  supply  of,  79 

polypi,  79 

septum,  76 
Nates,  fold  of,  426 
Nasopharyngeal  adenoids,  116 

polypi,  117 
Nasopharynx,  116 
Neck,  117 

abscess  of,  143 

deep  fascia  of,  141 

embryology  of,  145 

tistuliB  of,  145 

landmarks  of,  117 

lung  and  pleura  in,  215,  218 

lymph  nodes  of,  144 

surface  markings  of,  117 

triangles  of,  120 

vessels  of,  121,  122,  125-129 

wounds  of,  131 
Nelaton's  line,  345,  427,  434,  439 
Nephrectomy,  338 
Nephro-lithotomy,  338 
Nephrorrhaphy,  338 
Nephrotomy,  338 
Nerve  supply  of  lower  limb,  482 

of  upper  limb,  200 
Nerves  (see  various  regions) 

division  of  (see  various  regions) 

exit     of,     from    spinal     cord,     494^ 
495 
Neuralgia,  trigeminal,  85,  86 
Nipple,  210 

afiiections  of,  210 

line,  203 

position  of,  203,  210 
Nipples,  supernumerary,  211,  212,  431 
Nose  bleed,  79 

blood  supply  of,  79 

cartilaginous  part  of,  74 

coverings  of,  73 

external,  72 

foreign  bodies  in,  80 

operations  on,  74 
Notch  of  Rivini,  51 
Nuck,  canal  of,  391,  397 
Nymphfe,  397  C^, 


INDEX. 


513 


OBLIQUE  inguinal  hernia,  26:{ 
muscles  of  abdomen,  239,  241 
aponeuroses  of,  243 
of  orbit,  08 
Obturator  artery,  272 

canal,  355 

fascia,  356,  422,  424 

foramen,  355,  440 

hernia,  355 

nerve,  355 

paralysis  of,  482 

or  thyroid  dislocation  of  hip,  440 
Occipital'artery,  21,  12(5 

lymph  nodes,  22 

protuberance,  external,  25,  118 

sinus,  37 

trianfile,  120 
Occipito-frontalis,   20,  22,  5»t 

aponeurosis  of,  19,  20,  22,  34 
CEdema  of  eyelids,  60 

of  glottis,  134 

of  hand,  195 

of  scrotum,  410 
CEsophagotomy,  234 
(Esophagus,  233 

caliber  of,  233 

cancer  of,  234 

constrictions  of,  233 

direction  of,  233 

diverticula  of,  146,  235 

foreign  bodies  in,  234 

length  of,  233 

operations  on,  234 

stricture  of,  234 

relations  of,  229,  230,  234 
Olecranon,  175,  179 

fractures  of,  183 
Olfactory  nerve,  78 
Omental  grafts,  287 

adhesions,  287 

sac,  lesser,  289,  295,  332 
Omentum,  great,  286 

in  hernia,  287 

small,  2S8,  332 
Orao-hyoid,  120 
Ophthalmic  vein,  37,  62,  71 
Optic  nerve,  69 

and  subanichnoid  space,  69 
Orbicularis  oris,  85 

palpebrarum, 59,  84 
Orbit,  65 

abscess  of,  72 

aponeurosis  of,  66 

axis  of,  65,  66 

dimensions  of,  65,  Wi 

foreign  Ijodies  in.  72 

fractures  of,  65 

muscles  of,  67,  68 

nerves  of,  69 

])aralysis  of,  70 

pulsating  tumors  of.  71 

relations  of,  65,  i\i\ 

region  of,  59 

vessels  of,  71 
Orchitis,   413 
Os  calcis,  fractures  of.  481 

33 


Os  innominatum,  348 
Os  magnum,  position  of,  188 
Ossicles  of  ear,  52,  54 
Ovary,  385 

development  of,  387 

fossa  of,  385 

[)alpation  of,  386 

pedicle  of,  386,  391 

position  of,  385,  386 

relations  of,  360,  388 

structure  of,  386 

tumors  of,  387 

vessels  of,  387 
Oviduct,  388 

PACCHIONIAN  bodies,  29,  39 
Palate,  107 

aponeurosis,  108 

blood  supplv  of,  108,  110 

cleft,  110     " 

operations  on,  108,  109,  111 
formation  of,  110 
hard,  107 
muscles  of,   108 
s.-,ft,  108 
Palatine  arterv,  posterior,  108,  110 
Palm,  193 

abscess  of,  196 
creases  of,  193 

cutaneous  nerve  supply  of,  198 
motor  nerve  supplv  of,  198 
skin  of,  194 
Palmar  arch  deep,  197 
superficial,  197 
fascia,  195 
Palmaris  longus  tendon,  188 
Palpebral  conjunctiva,  61 

ligaments,  61 
Pampiniform  plexus,  387,  415-417 
Pancreas,  332 
cysts  of,  333 
disea.ses  of,  333 
duct  of,  328 
operations  on,  332 
position  of,  332 
relations  of,  332 
Pancreatitis,  333 
Papilla  of  duodenum,  299,  328 

of  eyelid,  62,  63 
Paracentesis  of  the  aUlomen,  285 
[>ericardiun),  215,  224 
thorax,  20t;,  207 
tympanum,  52 
Paralv.sis    in    spinal      injuries,    494-196 
"498 
of  anterior  i-rural  nerve,  4S2 
cervical  symiiathetic,  71 
external  popliteal  nerve,  482 
facial  nerve.  84 
fourth  cranial  nerve,  70 
great  sciatic  nerve,  482 
internal  poj)liteal  nerve,  482 
median  nerve,   19S 
musculo-spiral  nerve,  173 
obtunitor  nerve,  482 
sixth  cranial  nerve,  70 


514 


INDEX. 


Paralysis  of  third  cranial  nerve,  70 

ulnar  nerve,  198 
Paraphimosis,  406 
Parietal  eminence,  25 
fissure,  27 
foramen,  26 

and  visceral  anastomoses  of  abdomen, 
249,  342 
Parieto-occipital  fissure,  46 
Parotid  absce.ss,  89,  90 
compartment,  88 
gland,  89 

relations  of,  89 
structures  in,  90 
nerve  supply  of,  90 
removal  of,  92 
lymph  nodes,  22,  91 
region,  88 
sheath,  88 
tumors,  91 
Parovarium,  387 
Parumbilical  vein,  249,  342 
Patella,  449  _ 

dislocation  of,  457 
floating  of,  458 
fractures  of,  451,  455-456 
Patellar  click,  458 

ligament,  449,  455,  457 
lateral,  451,  455—457 
rupture  of,  456 
Pectineal  compartment,  269 
fascia,  269 

Pectoralis  major,   148,  155,  167,  169,  170, 
208 

minor,  149,  155,  167 
Pedicle,  ovarian,  386,  391 
Pelvic  arches,  348 

cellulitis,  275,  357,  390 

counter  arches,  348 

deformities,  349 

diaphragm,  354 

hematocele,  357,  387,  391,  393 

hernia?,  355 

peritonitis,  357 

symphysis,  345,  348 

viscera,  358 
Pelvis,  axis  of,  284,  351 

diameters  of,  351 

floor  of,  354 

fractures  of,  349 

in  female,  352 

landmarks  of,  345 

mechanism  of,  348 

movements  of,  352 

nerves  of,  357 

obliquitv  of,  351 

outlet  of,  346,  354 

planes  of,  351 

vessels  of,  357 
Penetrating    wounds     of    abdomen,     252, 

284 
Penis,  405 

angle  of,  408 

dorsal  vein  of,  356,  403,  407,  422 


Penis,  erection  of,  407,  421,  498 

fascia  of,  407 

layers  of,  405-407 

malformations  of,  409 

suspensory  ligament  of,  408 
Perforating  ulcer,  474 
Pericardium,  223 

effusions  in,  224 

elasticity  of,  224 

tapping"of,  215,  224 
Pericranium,  20 
Perineal  body,  361,  424 

fascia,  419 

hernia,  356 

incisions,  418,  420,  422,  423 

interspaces,  419,  420,  421 

ledge,  419,  420,  424 
Perinephritic  abscess,  282,  335,  336 
Perineum,  361,  417 

boundaries  of,  418 

central  point  of,  418,  424 

depth  of,  418 

divisions  of,  418 

fascist  of,  419,  420,  422 

female,  423 

landmarks  of,  418 

layers  of,  419-422 

median  raphe  of,  418 

muscles  of,  420,  421 

"proper,"  419 

rupture  of,  424 
Peritoneal  absorption,  286 

adhesions,  285 

cavity,  285 

sac,  lesser,  289,  295,  332 

transudation,  286 
Peritoneum,  elasticity  of,  285 

parietal,  284 

visceral,  286 
Peritonitis,  284,  286 
Perityphlitic  abscess,  275 
Peroneal  artery,  461,  463,  473 

muscles,  477 

tendons,  466,  467,  472 
contracture  of,  468 
displacement  of,  467,  478 

tubercle,  472 
Pes  cavus,  474,  477,  478 
Petit' s  triangle,  241,  280 
Petrosal     nerve,    great     superficial,     84, 
108 

sinuses,  37,  38 
Petro-squamous  suture,  53 
Peyer's  patches,  304 
Phantom  tumor,  243 
Pharyngeal  artery,  ascending,  112 

tonsil,  58 
Pharyngomaxillary  space.  111 
Pharvngotomy,  subhyoid,  116,  131 
PharVnx,  113 

divisions  of,  116 

foreign  bodies  in,  114 

relations  of,  114 
Phimosis,  406 

Phrenic  nerve,    121,   157,   213,   229,   232, 
325,  343,  498 


IXDLX. 


515 


Phreno-colic  ligjunent,  ol7,  :V29 

-splenic  ligament,  .329 
Pia  mater,  39 
Pigeon  breast,  202,  221 
Piles,  -MVA 
Pinna,  47 

Pirogofl's  amputation,  481 
Plantar  arch,  wound  of,  473 

arteries,  4G(;,  473,  481 

fascia,  4(57,  474,  477,  478 
tenotomy  of,  47.") 

ligaments,  47<),  477 
Plantaris  tendon,  rupture  of,  462 
Platvsma  mvoides,  123 
Pleura,  214' 

borders  of,  21') 

dome  of.  122,  21o 

in  lumbar  incisions,  215,  282,  335 

limits  of,  215 

wounds  of,  21(5,  217 
Pleural  adhesions,  217,  220 
Pleurisy,  217 
Plica  semilunaris,  245 
Pneumatocele,  56 

Pneuinogastric  nerve,  222,  229,  231,  343 
Pneunumia,  220 
Pneumothorax,  217 
Pollitzer's  method  of  inflating  the  middle 

ear,  57,  116 
Polypus  of  nose,  79 
Popliteal  abscess,  451 

aneurism,  452 

artery,  450,  452,  459,  463 

bursio,  453 

fascia,  451 

nerves,  external,  450,  452 
internal,  450,  452 
paralysis  of,  482 

nodes,  453,  475 

region,  450 

vein,  450,  452,  453 
Portal  vein,  2S8,  324 
Posterior  auricular  artery,  21,  47 

condylar  vein,  37 

scapular  arterv,  157 

tibial    arterv,'   4(11,    463,    465,    466, 
473 
Post-prostatic  pouch,  371 
Pott's  disease,  251,  486 

fracture,  470 
Processus  vaginalis,  261,  264,  412 
Poupart's  ligament,  243,  261,  269,  274 
Prejiatella  bui"sii,  451 

bursitis,  451 
Prejiuliic  curve  of  urethra,    lOO.  403 
Prepuce,  405,  406 
Priapism,  407,  498 
Profunda  arteries  of  arm,  171 

femoris,  431,  433 
Prolapsus  ani,  358,  .362 

uteri,  383,  392-394 
Pronation,  185 
Pronator  radii  teres,  184,  185 
Pronator  (picidratus,  186 
Prostate,  373 

abscess  of,  361,  375 


Prostate,  capsule  of,  :}56,  375,  422 

enlargement  of,  361,  373,  375 

lobes  of,  374,  399 

operations  on,  376,  42.3 

position  of,  374 

relations  of,  :i59,  .360,  .361,  :;74,  422 

structure  of,  375 
Prostatectomy,  374 
ProstJitic  plexus  of  veins,  375 

sinuses,  399 
Prostato-peritoneal  aponeurosis,  .359 
Psoas  absces.s,  269,  278,  486 

muscle,  432,  444 
Pterion,  26 
Pterygium,  62 
Pterygoid  muscles,  95,  96 
Pterygo-maxillary  ligament,  107 
Ptosis,  61 
Pubic  crest,  238,  345 

spine,  238,  274,  427,  4.30 
Pubo-femoral  band,  435,  436 

-prostatic  ligaments,  356 
Pudendal  hernia,  .356 
Pudic  artery,  internal.  355 

nerve,  internal,  355 
Pulmonary  artery,  221,  222,  228-231 

orifice,  226 

plexus,  222 

veins,  222 
Puncta  lachrymalia,  62,  63 
Puncture  of  bladder,  360,  367 
Pylorus,  operations  on,  294 

position  of,  202 

relations  of,  292 

stricture  of,  297 

tumors  of,  297 
Pyosalpinx,  388,  389 
Pvramidalis  muscle,  243 
Pyriformis,  354,  357 

QUADRATUS  femoris,  440 
lumborum,  281,  316 
Quadriceps,  449,  455,  457,  458 
expansion,  451,  457 
tendon,  455,  456 
rupture  of,  456 
Quinsy,  112 

I^ADIAL  arterv.  184,  188,  189 
ll     nerve,  184-187,  198 

l)ulse,  188 
Radio-carpal  joint,  187 

ulnar  joint,  190 
Radius,  183 

dislocation  of,  180 

fracture  of,  183,  185 

head  of,  175,  179 

styloid  process  of,  187,  191 
Ranine  arterv,  104 

vein,  104 
Ranula,  107 
Rectal  examination,  346,  360 

polvpi,  358 

tuU-,  318 
Rectocele,  394 
Recto-uterine  i)ouoli,  380 


51(5 


INDEX. 


Recto-vaginal  fistula,  394 
pouch,  360 
septum,  394 

-vesical  fascia,  356,  369,  422 
pouch,  359,  360,  366,  372 
Rectus  abdominis  muscle,  242,  254 
sheath  of,  245,  253 

femoris,  444,  44G 
Rectum,  358 

anal  portion  of,  361 

attachments  of,  359 

development  of,  364 

divisions  of,  358 

examination  of,  360 

excision  of,  359 

foreign  bodies  in,  358 

introduction  of  hand  into,  359 

nerve  supply  of,  363,  498 

operations  on,  365 

pelvic  portion  of,  358 

prolapse  of,  358,  362 

relations  of,  359,  374,  380,  422 
to  peritoneum,  359 

stricture  of,  362 

structure  of,  361 

vessels  of,  362 
Recurrent  laryngeal  nerve,  133,  135,  140, 

229,  230 
Reduction  en  masse,  268 
Reflexes  of  cord,  491,  494 
Reid's  base  line,  44 
Renal  abscess,  335,  336 

arterv,  337,  342 

calculus,  337,  338,  341,  360 

colic,  341 

plexus,  338 

vessels,  337 
Resections  (see  various  parts) 
Respiration  in  fracture  of  spine,  498 
Respiratory  wave  in  veins,  129 
Retention  of  urine,  370,  498 
Retro-flexion  of  uterus,  382 

-pharyngeal  abscess,  114,  143 

-version,  of  uterus,  382 
Rhinoplasty,  74 
Rhinoscopy,  75 
Rhomboid  ligament,  153 
Ribs,  205 

cervical,  122 

counting  of,  203,  282 

excision  of,  206 

fractures  of,  205 

rudimentary,  12,  282,  334,  335 
Right  auricle,  226,  227 

lymphatic  duct,  233 

ventricle,  225-227 
Rima  glottidis,  133 
Ring,  abdominal,  261,  262 

crural,  270,  431 
Rolando,  fissure  of,  44 
Root  of  lung,  220,  222,  229 
Rosenmiiller,  fossa  of,  58,  116 
Rouge's  operation,  74 
Round  ligaments,  380,  383,  387,  391 
course  of,  391 
shortening  of,  268,  392 


C  ACRAL  dimple,  238 
0     Sacro-coccygeal  joint,  346 
tumors,  346 
-iliac  joint,  347-349,  427 
abscess  of,  347 
disease  of,  347 
ligaments,  347,  348 
-sciatic  ligaments,  346,  418,  426 
-vertebral  angle,  25,  26,  346 
Sacrum,  means  of  holding  it  in  place,  347 
promontory  of,  346 
wedge-shape  of,  347 
Sagittal  fontanelle,  28 

suture,  26 
Salivary  fistulae,  87 
Saphenous  nerve,  external,  462,  463 

internal,  433,  446,  447,  450,  459, 
462-464 
opening,  272,  431,  432 
vein,   long,   431,  433,  446,  450,  459, 
461,  462,  464,  466,  474 
short,  450,  461-4()3,  466,  474 
Sartorius,  430,  433,  444,  446,  447 
Scalenus,  anterior,  120,  122 
Scalp,  18 

abscess  of,  23 
aponeurosis  of,  20 
arteries  of,  21 
bleeding  from,  22 
dangerous  area  of,  20 
fatty  tissue  in,  19 
hsematoma  of,  23 
hair  of,  19 
incisions  in,  21 
lymphatics  of,  22 
mobility  of,  20 
nerves  of,  22 
neuralgia  of,  22 
pericranium  of,  20 
sebaceous  tumors  of,  19 
skin  of,  19 

subaponeurotic  areolar  layer  of,  20 
subcutaneous  tissue  of,  19 
suppuration  in,  20-23 
temporal  region  of,  24 
vascularity  of,  20 
vessels  of,  20 
wounds  of,  20,  22 
Scaphoid  bone,  188,  467,  472,  477,  480 
Scapula,  147,  156,  204,  484 
excision  of,  157 
fractures  of,  156 
Scapular  line,  203 
Scarpa's  triangle,  430,  446 
fascia  of,  431,  432 
landmarks  of,  430 
lymph  nodes  of,  431,  434 
region  of,  430 
topography  of,  431 
vessels  of,  431,  432 
Sciatic  artery,  355,  427,  429 

nerve,  great,  355,  427,  429,  446,  447 

exj)osure  of,  427 

paralysis  of,  482 

stretching  of,  430 

notch,  great,  355,  427,  444 


INDEX. 


517 


Sciatica,  429,  430 
Scoliosis,  202,  487 
Scrotal  iifrariiont,  411,  41  1 
Scrotum,  -10!) 

blood  supply  of,  411 
develoi)ment  f)f,  412 
in  elephantiasis,  412 
in  (I'denia,  410 
layers  of,  40!l-411 
Semilunar  cartila<,'es  of  knee,  457 
dislocation  of,  457 
fold  of  Dou<,das,  245 
f^anglia,  34.") 
line,  238,  244,  258 
Semimembranosus  tendon,  450,  452 
Seminal  vesicles,  'M\0,  .'{74,  870,  428 
position  of,  870,  877 
relations  of,  877 
Semitendinosus  tendon,  450,  452 
Septum  crurale,  248,  271 

of  nose,  70 
Serratus  raagnus,  150 
Seventh  cranial  nerve,  59,  60,  84,  90,  108 
Sheath  of  rectus,  248 
Shingles,  251 
Shoulder,  147 

anterior  region  of,  149 
bursie  about,  158,  159 
deltoid  region  of,  157 
dislocations  of,  100 
fractures  about,  1()4-166 
joint,  159 

amputation  at,  167 
disease  of,  159 
excision  of,  106 
posterior  region  of,  1?5 
surface  landmarks  of,  147 
topography  of,  149 
Sigmoid  llexure,  317 
Sinus  cavernous,  87,  62 

great,  of  aorta,  228,  229 
lateral,  course  of,  36 
sigmoid,  80 

course  of,  87 

relation   to  mastoid  antrum  and 
cells,  5() 
superior  longitudinal,  30 
Sinuses  of  dura,  8>0 

mechanism  to  prevent  aspiration 
of,  38 
Morgagni,  110 
Valsalva,  229 
Sixth  cranial  nerve,  70 
Skull,  2.5 

abnormalities  of,  18,  27 
blood  supply  of,  28 
buttresses  of,  29 
construction  of,  28 
deformities  of,  27 
development  of,  27 
elasticity  of,  80 
emissary  veins  of,  21 
fractures  of,  80 
bitse  of,  81 

mechanism  of,  82 
vault  of,  8! 


Skull,  fractures  of  vault  of,  symptoms  and 
danger  of,  31 
growth  of,  18 
neerDsis  of,  28 
of  female,  17 
of  idiot,  17 
of  infant,  17 
pericninium  of,  20 
racial  fliiTereiues  of,  IS 
soft  parts  covering,  IH 
surface  lan<lmarkH  of,  25 
sutures  of,  20 
thickness  of,  28 
topography  of,  20 
trepiiining  of,  29 
veins  of  the  diploi;  of,  22 
Small  intestine,  297 
Soft  palate,  108 
Solar  plexus,  281,  343 
Solcus,  4()1,  402 
Spasmodic  stricture,  399 
Spastic  paralysis,  494 
Speech  areas  of  bniin  cortex,  42 
Spermatic  artery,  415-417 
colic,  376 
cord,  202,  271,  410 
fascia,  external,  240,  201,  410 
plexus  of  veins,  415-417 
Sphenoidal  sinuses,  82 
Spheno-uiaxillary  fossa,  82 
Sphincter  ani,  301,  304,  425 

of  bladder,  internal,  868,  375,  404 
Spina  bifida,  487,  488,  492 
Spinal  abscess,  486 

accessory  nerve,  108,  119 
canal,  487 

cocjiinization,  489,  492 
cord,  491 

anaesthesia  due  to  injurv  of,  494, 

495 
concu&sion  of,  493 
compression  of,  491,  493 
conduction  paths  of,  493 
contusion  of,  493 
defecation  in  injuries  of,  498,  499 
level  of  lesion  of,  494 
localization  of  injury  of,  494,  495 
maimer  of  suspension   in    canal, 

491,  492 
micturition    in    injuries  of,    498, 

499 
motor  paralvsis  due  to  injurv  of, 

498-490 
operations  on,  499 
respiration  in  injuries  of,  498 
segments  of,  494,  495 
topograjiliy  of,  491 
tumors  of,  499 
curvature,  202,  485-487 
duni,  491 ,  492 
furrow,  279 

haiuorrha.gi\  491-493.  498,  499 
meninu'es.  427,  491,  492 
meningitis,  492 

nerves,  points  of  origin  of,  494,  495 
reflexes.  491,  494,  498,  499 


518 


INDEX. 


Spine,  484 

caries  of,  278,  486 

curvature  of,  202 

curves  of,  484 

fractures  and  dislocations  of,  489-491, 

493 
functions  of,  484 
laminectomy  of,  491 
landmarks  of,  484 
movements  of,  488 
sprains  of,  489 
topography  of,  484 
of  ischium,  346,  427 
of  scapula,  147,  219 
Spinous  processes,  fracture  of,  490 
Splanchnic  nerves,  231,  343 
Spleen,  329 

artery  of,  331 
displacement  of,  330 
enlargement  of,  330 
extirpation  of,  331 
held  in  position  by,  329 
injuries  of,  330 
position  of,  329 
relations  of,  331 
rupture  of,  330 
size  of,  330 
Splenectomy,  331 
Splenic  flexure,  317 
Spongy  portion  of  urethra,  400 
Squamous  suture,  26 
Stenson's  duct,  87 
Sternal  line,  203 
Sterno-clavicular  joint,  152 
diseases  of,  153 
dislocations  of,  152 
-hyoid  muscle,  136,  139-141 
-mastoid,  118 

in  torticollis,  119 
-xiphoid  joint,  203 
Sternum,  204 

fractures  of,  204 
holes  in,  204 
operations  on,  204 
Stomach,  287,  290 
axis  of,  293 
cancer  of,  297 
curvatures  of,  290-292 
ectasia  of,  292 
foreign  bodies  in,  290 
hernia  of,  297 

hourglass  contraction  of,  291,  297 
lymphatics  of,  144,  296 
nerves  of,  296 
operations  on,  293 
position  of,  291 

maintained  by,  294 
ptosis  of,  292 
relations  of,  294 
shape  of,  290 
size  of,  291 
ulcer  of,  296 
vessels  of,  295 
wall,  295 
wounds  of,  295 
Strabismus,  68 


Stricture  (see  various  parts) 
Styloid  process,  91,  115 
Stylo-raaxillary  ligament,  88,  142 
Subacromial  bursa,  158 
Subarachnoid  fluid,  39 
space,  38,  489,  492 
Subastragaloid  amputation,  480 

dislocations,  479 
Subclavian  artery,  121,  122,  151,  215 
ligation  of,  121 

collateral    circulation    after, 
122 
triangle,  120 
vein,  121,  151 
Subclavius  muscle,  151 
Subcrural  bursa,  458 
Subdural  space,  35,  492 
Subhepatic  space,  328 
Subhyoid  region,  126 
Sublingual  artery,  125 
bursa,  107 
gland,  106 
Submaxillary  gland,  124 
sheath  of,  124 
lymph  nodes  of,  124 
triangle,  123 
Subperitoneal  connective  tissue,  358,  367, 

381,  422 
Subpubic  curve  of  urethra,  400,  401-403 

angle,  345 
Subscapular  artery,  157,   164 
Subscapularis,  161 
Superficial  cervical  nodes,  144 
Superior  carotid  triangle,  126 

larvngeal  nerve,   106,  ^126,   131,  133, 

135 
longitudinal  sinus,  36 
maxilla,  92 

cleft  of,  110 
excision  of,  93 
fractures  of,  92 
how  held  in  position,  92 
necrosis  of,  92 
tumors  of,  92,  94,  102 
thyroid  artery,  126 
vena  cava,  222,  228,  231 
Supination,  185 
Supinator,  185 
Supraclavicular  fossa,  120 
nerves,  120,  121,  149 
Supramastoid  crest,  25 
Supraraeatai  triangle,  54 
Supraorbital  foramen,  66 

nerve,  71 
Suprapubic  cystotomy,  359,  367 
Suprarenal  gland,  341 

relations  of,  341 
Suprascapular  artery,  121 

nerve,  157 
Supraspinatus,  161 
Sustentaculum  tali,  472,  477 
Sutures  of  skull,  26 

closure  of,  27 
diastasis  of,  26 
position  of,  26 
Suture  membrane,  26 


INDEX. 


519 


Sylvius,  fissure  of,  45 
Syme's  amputation,  481 
Sympathetic  nerves,  abdominal,  343 

cervical,  129 

cervical  ganglia  of,  130 

of  eye,  71 

thoracic,  pressure  on,  232 
Symphysiotomy,  348 
Symphysis  pubis,  34-'),  348 
Synovial  cavities  of  foot,  480 

of  wrist,  192 
sheaths  of  aniile,  467 

of  lingers,  197 

of  palm,  19(3 

of  wrist,  189 

TABATIERP:  anatomique,  188 
1     Talipes  calcaneus,  478 
cavus,  475 
equinus,  478 
planus,  477 
valgus,  477,  478 
varus,  478 
Tapping  the  abdomen,  285 

pericardium,  215,  224 
jjleura,  20(5,  207 
Tarsal  bones,  fractures  and  dislocations  of, 
480,  481 
cartilages,  01 
tumor,  63 
Tai*so-metatarsal  joints,  473 

amputation  tiirough,  480 
Tarsus  (see  foot) 
Taxis,  261 
Teeth,  101 

enamel  of,  102 
eruption  of,  101 
Hutchinson's,  102 
Tegmen  antri,  55 
tympani,  53 
Temporal  abscess,  24 
artery,  21 
fascia,  24 
fossa,  24 
region,  24 
fat  in,  25 
fractures  in,  31 
Temporo-mandibuliir  articulation,  96 
anchyk)>is  of,  98 
dislocation  at,  96 
-maxillarv  vein,  91 
Tendo  Achillis,  461,  462,  466 
bursa  beneatii,  468 
contracture  of,  4()8 
rupture  of,  462,  481 
tenotomy  of,  463 
oculi,  til,  ()4 
Tenon's  capsule,  66 
Tenotomy  of  iiamstrings,  452 

external  popliteal  nerve  in,  452 
slernoniastoid,  119 
tendo  Aciiillis,  463 
tibialis  anticus,  468 
posticus,  46S 
Tensor  palati,  108,  109 
Testis,  412 


i  Testis,  attachment  of,  411,  412 

castration  of,  410,  416,  417 

consistence  of,  413 

descent  of,  264,  412 

development  of,  412 

hernia  of,  413 

inversion  of,  412,  415 

nerve  su|)piy  of,  415 

position  of,  412 

retained,  413 

tunic  of,  413 

vessels  of,  415 
Tetanus,  98 
Thenar  eminence,  193 
Thigh,  445 

amputation  of,  446,  448 

fascia'  of,  446 

fractures  of,  447 

region  of,  445 

skin  of,  44() 

surface  landmarks  of,  446 

topography  of,  446 

vessels  of,  447 
Third  nerve,  61,  69 
Thoracic  aneurism,  230 

aorta,  230 

duct,  229,  230,  232 
wounds  of,  232 

nerve,  long,  1()8 

nerves,  207,  242,  250,  251,  343 

spine,  4,S4,  488 

walls,  landmarks  of,  203 
layers  of,  204 
vessels  of,  206 
Thoracico-epigastric  vein,  249,  342 
Thorax,  201 

boundaries  of,  203 

deformities  of,  202 

form  of,  201 

paracentesis  of,  206,  207 

viscera  of,  214-235  (inch) 

walls  of,  201 
Tiuimb,  dislocation  of,  199 
Thvnuis,  remains  of,  216.  228 
TliyrogK)ssal  duct,  104,  107 
Thyro-hyoid  lunsa,  131 

membrane,  US.  131 
Thyroid  artery,  inferior,  140 
superior.  1  |0 

body,  138 

accessory  luutions  of,  139 
enlargement  of,  139,  140 
function  of,  140 
opcnilions  on.  141 
position  of,  138 
relations  of,  139 

cartilage,  US 

isthnnis,  138 

in  tracheoti>mv,  136 

veins,  136,  14(t 
Tiiyroidea  inia  artery,  llU),  231 
Tibia,  bonlers  of,  460 

epij.hvses  of,  459,  460,  472 

fractures  of.   1('.0,  464,  470,  471 

in  rickets,  465 

strength  of  shaft  of,  464 


520 


INDEX. 


Tibia,  tubercle  of,  449,  455,  456 

tuberosities  of,  449 
Tibial  artery,  anterior,  461,  463,  465,  473 
posterior,  461,  463,  465,  466,  473 
bifurcation  of,  466 

nerves,  477 
Tibialis  anticus,  461,  466,  467,  477 
tenotomy  of,  468 

posticus,  466,  467,  477 
tenotomy  of,  468 
Toe,  great,  amputation  of,  481 

dislocation  of,  481 
Tongue,  102 

blood  supply  of,  104,  105 

excision  of,  104 

held  in  place  by,  102,  103 

in  ana?stliesia,  102 

lymphatics  of,  105 

mucosa  of,  104 

nerve  supply  of,  106 

new  growths  of,  1 04 
Tongue-tie,  103 
Tonsil,  lingual,  104 

Luscbka's  or  pharyngeal,  58,  116 
Tonsils,  111 

bleeding  from,  112 

blood  supply  of,  113 

hypertropiiy  of,  112 

position  of,  112 
Torticollis,  119 
Trachea,  118,  135 

diameter  of,  137 

foreign  bodies  in,  138,  223 

in  the  thorax,  222 

relations  of,  136,  229 
Tracheotomy,  136 
Tracts  of  spinal  cord,  493 
Transversalis  fascia,  245,  246,  262 

muscle,  241 

posterior  aponeurosis  of,  280 
Transverse  cervical  artery,  121 

colon,  287,  316 

process  of  the  atlas,  118 

sixth  cervical  vertebra,  118 
Trapezius,  120 
Trapezium,  188 
Trapezoid  ligament,  154 
Treitz'  fossa,'  300 
Trendelenburg's  position,  367 
Trephining,  29 
Triangle,  anterior  of  neck,  123 

at  elbow,  174 

carotid,  126 

occipital,  120 

of  Petit,  241,  280 

posterior  of  neck,  120 

Scarpa's,  430,  446 

submaxillary,  124 

subclavian,  120 
Triangles  of  neck,  120 
Triangular  fibro-cartiiage,  190 

ligament,  244,  261 

of  the  urethra,  35(),  399,  420-422 
Triceps,  178 

Tricuspid  valve,  position  of,  226 
Trigeminal  nerve,  70,  85 


Trigone,  360,  392,  393 
Trismus,  98 

Trochanter,  great,  426,  427,  434,  439,  440, 
444 

bursEc  over,  429 
Tubal  ]iregnancy,  388 
Tube,  Eustachian,  56 

Fallopian,  388 
Tuber  ischii,  345,  348,  426,  429 
Tuberosity  of  humerus,  great,  148,  161 
Tubo-ovarian  ligament,  386,  388 
Tunica  albuginea,  387,  413 

vaginalis,  411,  414 
Tympanic  membrane,  51 

otoscopic  image  of,  51 
rupture  of,  32 
Tympanites,  286 
Tympanum,  52 

TTLCER  of  duodenum,  299 
LI      of  stomach,  296 
Ulna,  183,  185 

dislocation  of,  178 
fracture  of,  185 
styloid  process  of,  187,  191 
Ulnar  artery,  183,  188 

nerve,    171,   172,   175,   178,  184,   187, 
188,  198 
paralysis  of,  198 
Umbilical  cord,  257 
fistula,  259 
hernia,  257-259 
region,  257 
Umbilicus,  238,  257 
fibrous  ring  of,  258 
position  of,  238 
vessels  of,  258 
Umbo  of  membranum  tympani,  51,  52 
Upper  extremity,  147 
Urachus,  259 
Ureter,  339 

course  of,  339 

distension  of,  339 

in  female,  339,  393 

length  of,  339 

operations  on,  341 

relations  of,  339,  340,  386,  389 

to  uterine  vessels,  339 
varieties  of,  340 
vesical  end  of,  367,  371 
Urethra,  female,  361,  393,  395 
course  of,  395 
direction  of,  396 
external  meatus  of,  396 
male.  398 

anterior,  402 
bulbous  portion  of,  400 
caliber  of,  402,  403 
catheterization  of,  400,  405 
changes  according  to  age  of,  404 
curve  of,  401,  40;{ 
distensibilitv  of,  403 
divisions  of,"  398 
external  meatus  of,  400 
fixed  portion  of,  400,  401 
internal  meatus  of,  366,  371,  403 


INDEX. 


521 


Uretlini,  rasile,  length  of,  402 
raeinljrunous,  oGl,  .'i'.lO 
movable  [joition  of,  401 
mucosa  of,  401 
narrowest  parts  of,  40.3 
posterior,  402 
prostatic,  376,  398,  403 
relations  of,  301,  420 
rui)tiire  of,  405 
sphincters  of,  395,  404 
spongy  portion  of,  400 
stricture  of,  400 
Urethral  (;aruncle,  390 

triangle,  418 
Urethritis,  402,  405 
Uterine  artery,  382 

tibroids,  384 
Utero-ovarian  ligament,  386,  387 

-vesical  pouch,  372,  380 
Uterus,  379 

axis  of,  379,  380 
development  of,  384 
displacements  of,  382 
fixation  of,  380 
ligaments  of,  380 
lymphatics  of,  385 
masculinns,  399 
position  of,  379 
prolapse  of,  383,  392-394 
relations  of,  360,  380,  381 
vessels  of,  384 
wall  of,  383 
Uvula,  109 
vesicae,  371 

VAGINA   392 
relations  of,  360,  390,  392-394 

structure  of,  394 

walls  of,  392,  393 
Vaginal  cystocele,  393 

examination,  346,  381,  393 

fornices,  381,  394 

hernia,  356 

rectocele,  394 
Vaginismus,  394 
Vagus  nerve,  222,  229,  231,  343 
Valsalva's  method  of  inflating  miildlc  ear, 

57 
Valve,  ileo-ca^cal,  308 
Valves  of  heart,  position  of,  226 
Varicocele,  417 
Varicose  veins,  463,  464 
Vas  deferens,  360,  367,  378,  416 
artery  of,  379 

|i()sili()n  and  relations  of,  378 
Vascular  compartment,  269 
Veins  (see  various  parts) 

air  in,  129.  144 

emissary  of  skull,  21 

of  diploi-,  22 
Velum  pendulum  palati,  109 


Vena  cava   inferior,   322,   328,    332,  334, 
340 

superior,  222,  228,  231 
\'ena  porta-,  288,  324 
Venesection  at  liie  enj<jw,  176 
\enlricles  of  heart,  225-228 
Vermiform  ajjpendix,  309 

blood  vessels  of,  313 

direction  of,  31 1 

lengtli  and  lumen  of,  309,  310 

mesenterv  of,  31(» 

position  of,  306,  307,  311 

relations  of,  30(i,  307 

vessels  of,  313 

wall  of,  312 
Vertebra,  caries  of,  278,  480 

prominens,  1 18,  484 
Vertebral  artei-y,  127 

coiunni,  4S4 
VeruuKjutanum,  376,  398 
Vesico-prostatic  plexus,  370,  375 
-pubic  nuiscle,  356 
-vaginal  fistula,  372,  393 
Vesicuhe  seminales,  360,  374,  376,  423 

capsule  of,  377 

operations  on,  378,  423 

position  of,  376,  377 

relations  of,  377 
Vestibule  of  moulli,  100 
Vitelline  duct,  257 
A'ocal  cords,  133 
Volvulus,  318 
Vulva,  397 
Vulvo-vaginal  abscess,  397 

gland,  397 

WAKDKOP'S  operation,  127 
iT       ^Veaver's  bottom,  429 
"Wharton's  duct,  106 
White  line  at  anus,  361 

in  pelvic  fascia,  350,  424 
Whitlow,  199 
Willis,  circle  of,  127 
Wolfiian  tubules,  387 
VVormian  bones,  27 
Wrist,  joint,  189 

amputation  at,  192 
dislocations  at.  190 
epii)hyseal  se|ianition  at,  192 
excision  of,  192 
fractures  about,  191 
movements  of,  190 
region  of,  187 
skin  creases  of,  187,  188 
surface'  landmarks  of,  187 
tenchins  al)out,  188,  189 
topograpiiv  of,  188 
Wry  neck,  119 

y  YOOMA,  21,  54,  87,  88,  90 
Ij     Zygomatic  foss;i,  96 


Catalogue  of  Books 


PUBLISHED    BY 


Lea  Brothers  6i  Company, 

706,  708  &  710  Sansom  St.,  Philadelphia. 
Ill  Fifth  Avenue,  New  York. 


<  >iii' iiiiitlu-iUi'iiis  call  \)i-  imrcliased  fnim  any  l>i)<)k>ellcr  in  liie  I  iiile<l 
~"tates  or  Canada,  or  they  will  be  delivered  by  express  or  mail,  carriage 
jiaid  to  any  address  on  receipt  of  the  printed  price. 


Jl-LY,    1902. 


STANDARD    MEDICAL   PERIODICALS. 


Progressive  Medicine. 

A  Quarterly  Digest  of  New  Methods,  Discoveries  and  Improvements  in  the  Medical  and 
Surgical  Sciences  by  Eminent  .\uthorities.  Edited  by  Dr.  IIobakt  .\mory  Hark.  In 
four  abundantly  illustrated,  clotii  boimd,  <x;tavo  volumes  of  400-oOO  pages  each,  issued 
quarterly,  commencing  with  March  each  year.     Per  annum  (4  volumes),  $10.00,  delivered. 

The  Medical  News. 

WEEKLY,  $4.00   PER   ANNUM. 
Each  number  contains  4S  quarto  pages,  abundantly  illustrated.     A  crisp,  fresh   weekly 
professional  newspaper.  

The  American  Journal  of  the  Medical  Sciences. 

MONTHLY,   $5.00    PER   ANNUM. 

Each  issue  contains  192  octavo  pages,  fully  illustrated.  The  most  advanced,  practical, 
original  and  enterprising  American  exponent  of  scientific  medicine. 

The  Medical  News  Visiting   List  for  1902. 

Four  styles,  Weekly  (dated  for  oO  patients);  Moiitiiiy  (undated,  f-ir  ]'2i)  patients  \)eT 
month);  Perpetual  (undated,  for  30  patients  weekly  per  year) ;  and  Perpetual  (undated,  for 
60  patienLs  weekly  per  year).  Each  style  in  one  wallet-shaped  book,  leather  bound,  with 
pociket,  pencil  and  rubber.     Price,  each,  $1.25.     Thumb-letter  index,  25  cents  extra. 


The  Medical    News  Pocket  Formulary. 

New  (4th  j  fdiiioii  careruily  revised  to  date.  Containing  1700  pri^criptions  representing 
e  latest  and  most  approved  methods  of  administering  remedial  agents  Strongly  bounii 
leather,  with  pucket  and  pencil.      Price,  $1.50,  net. 


the  latest  and  most 
in  leather,  wi 

COMBINATION    RATES. 

ALONE.  I.S  COMBISATIOS 

American  Journal  of  the  Medical  Sciences ^S-****  \  <8  no  ) 

Medical  News 4.00/'  [$16.00 

Progressive  Medicine 10.00  ) 

Medical  News  VisitinK    List 1.25 

Medical  News  Formulary 1.50,  net. 


In  all  $21.75  for  $17.00 

First  (uur  above  publications  In  cumbination        $10.75 

All  above  publications  In  combination 17.00 

Other  Combinations  will  be  quoted  on  request.      Full  Circular!  and  Specimens  tree. 


.15  02 


LEA     BROTHERS    &     CO.'S    PUBLICATIONS. 


ABBOTT  (A.  C).  PRINCIPLES  OF  BACTERIOLOGY:  a  Practical  Manual  for 
Students  and  Physicians.  Sixth  edition  enlarged  and  thoroughly  revised.  12mo.,  636 
pages,  with  111  engravings,  of  which  26  are  colored.     Cloth,  $2.75,  nel. 

ALLEN  (HARRISON).  A  SYSTEM  OF  HUMAN  ANATOMY;  WITH  AN 
INTRODUCTORY  SECTION  ON  HISTOLOGY,  by  E.  O.  Shakespeare,  M.D. 
Comprising  813  double-columned  quarto  pages,  with  380  engravings  on  stone  on  109  full- 
page  plates,  and  241  woodcuts.     One  volume,  cloth,  $23. 

A  TREATISE  ON  SURGERY  BY  AMERICAN  AUTHORS.  FOR  STUDENTS 
AND  PRACTITIONERS  OF  SURGERY  AND  MEDICINE.  Edited  by  Eos- 
WEI.1,  Pabk,  M.D.  Third  edition.  In  one  large  octavo  volume  of  1408  pages,  with 
692  engravings  and  64  plates.     Cloth,  $7.00,  net ;  leather,  $8.00,  net. 

AMERICAN  SYSTEM  OF  PRACTICAL  MEDICINE.  A  SYSTEM  OF  PRAC- 
TICAL MEDICINE.  In  Contributions  by  Eminent  American  Authors.  Edited  by 
AuRED  L.  LooMis.  M.D.,  LL.D.,  and  "\V.  Gjlman  Thompson,  M.D.  In  four  very  hand- 
some octavo  volumes  of  about  900  pages  each,  fully  illustrated.  Per  volume,  cloth,  $5  ; 
leather,  $6 ;  half  Morocco,  §7.  For  sale  by  subscription  only.  Prospectus  free  on 
application. 

AMERICAN  SYSTEM  OF  DENTISTRY.  IN  TREATISES  BY  VARIOUS 
A  UTHORS.  Edited  by  Wilbur  F.  Litch,  M.D.,  D.D.S.  In  three  very  handsome 
super-royal  octavo  volumes,  containing  about  3200  pages,  with  1873  illustrations  and  many 
full-page  plates.  Per  volume,  cloth,  $6 ;  leather,  $7.  For  sale  by  subscription  only. 
Prospectus  free  on  application  to  the  Publishers. 

AIMERICAN  TEXT-BOOK  OF  ANATOMY.    See  Gerrish,  page  7. 

AMERICAN  TEXT-BOOKS  OF  DENTISTRY.  IN  CONTRIBUTIONS  BY 
EMINENT  AMERICAN  A  UTHORITIES.  In  two  octavo  volumes  of  more  than  800 
pages  each,  richly  illustrated  : 

PROSTHETIC  DENTISTRY.     Edited  by  Charles  J.  Essig,  M.D.,  D.D.S., 

Professor  of  Mechanical  Dentistry  and  Metallurgy,  Department  of  Dentistry,  University 
of  Pennsylvania,  Philadelphia.  Second  Editiou,  807  pages,  with  1089  engravings. 
Cloth,  $6  ;  leather,  $7,  net. 

OPERA  TIVE  DENTISTR  Y.     Edited  by  Edward  C.  Kirk,  D.D.S.,  Professor 

of  Clinical  Dentistry,  Department  of  Dentistry,  University  of  Pennsylvania.  Second 
Edition,  857  pages,  897  engravings.     Cloth,  S6. 00;  leather,  S7.00,  neL 

AMERICAN  SYSTEMS  OF  GYNECOLOGY  AND  OBSTETRICS.  Gynecology 
edited  by  Matthew  D.  Mann,  A.M.,  M.D.,  and  Obstetrics  edited  by  Barton  C.  Hirst,. 
M.D.  In  four  large  octavo  volumes  comprising  3612  pages,  with  1092  engravings,  and 
8  colored  plates.     Per  volume,  cloth,  $5. 

ASHHURST  (JOHN,  JR.).  THE  PRINCIPLES  AND  PRACTICE  OF  SUR- 
GERY. For  the  use  of  Students  and  Practitioners.  Sixth  and  revised  edition.  In  one 
large  and  Ijandsome  Svo.  volume  of  llGl  pages,  with  656  engravings.  Cloth,  $6 ;  leather,  $7. 

A  SYSTEM  OF  PRACTICAL  IMEDICINE  BY  AMERICAN  AUTHORS.  Edited 
by  WiLLiA.M  Pepper,  ]\I.D.,  LL.D.  In  live  large  octavo  volumes,  containing  5573  pages 
and  198  illustrations.  Price  per  volume,  cloth,  $5.  Prospectus  free  on  application  to 
the  Publishers. 

A  PRACTICE  OF  OBSTETRICS  BY  AMERICAN  AUTHORS.  See  Jeuett, 
page  9. 

ATTFIELD  (JOHN).  CHEMISTRY;  GENERAL,  MEDICAL  AND  PHAR- 
MACEUTICAL. Sixteenth  edition,  specially  revised  by  the  Author  for  America. 
In  one  handsome   12mo.  volume  of  784  pages,  wuth  88  illustrations.     Cloth,  $2.50,  net.. 


Philadelphia,  706,  708  and  710  Sansom  St. — Neuf  York,  111  Fifth  Avenue. 


LEA    BROTHERS    &     CO.'S    PUBLICATIONS. 


BACON    ^GORHAM).     ON  THE  EAR.      Third    Edition.     <)ne   12mo.   volume,   430 

pages,  with    1:0  engravings  and  7   colored   plates,     (loili,  $'2.'J5,  ti^/, 

BALLENGER  (W.  L.;  AND  WIPPERN  .A.  G.  .  A  I'OCKET  TEXTBOOK 
OF  DISEASE.^  OF  THE  EYE,  EAR,  SOSE  AM>  THROAT.  Tirno.,  .^25 
pages,  with  148  illu.'ilnitionH,  and  G  colored  platen.  Cloth,  $2,  «</.  Flexible  red  leather, 
$2.50,  wt. 

BARNES  ^ROBERT  AND  FANCOURT).    A  SYSTEM  OF  OBSTETRIC  MFD- 

ICINE  AS  J)   sriKiEllY,   TUEOIIETICAL   AM)    C  LIN  If  A  L.     OcUvo,  ^72 
pages,  231  illustrations.     Cloth,  $>j. 

BARTHOLOW  'ROBERTS).     CHOLERA  ;  ITS  CA  USATIOS,  PREVENTION 

AND   TliEATMEN'J'.      12ri)o.,    127  pages,  with  9  illustration!'.     Cloth,  $1.25. 

BILLINGS  f  JOHN  S.).  THE  NATIONAL  MEDICAL  DICTIONARY.  Includ- 
ing 111  one  al|)hahel  Knglisli,  French,  (Ternian,  Italian  and  Latin  Te<'hnical  Terrns  used  Id 
Medicine  and  the  Collateral  .Sciences.  In  two  imperial  fK,tavo  volumes,  containing  l-')74 
pages  and  two  colored  plates.     Per  vol.,  leather,  $7.     Specimen  pagew  on  application. 

BLACK  fD.  CAMPBELL).  THE  URINE  IN  HEALTH  AND  DISEASE, 
AND  URINARY  ANALYSIS,  PHYSIOLOGICALLY  AND  PATHOLOUl- 
CALLY  CONSIDERED.     12mo.,  256  pages,  73  engravings.     Cloth,  $2.75. 

BLOXAM  (C.  L.).  CHEMISTRY,  INORGANIC  AND  ORGANIC.  With 
ExpcrimenUs.  New  American  from  the  lifth  London  edition.  In  one  handsome  octavo 
volume  of  727  pages,  with  292  illustrations.     Cloth,  $2;  leather,  $3. 

BRUCE    (J.    MITCHELL).     MATERIA    MEDIC  A    AND    THERAPEUTICS. 

Si.xth  edition.     In  one  iL'ino.  volume  of  600  pages.    Cloth,  $L50,  tjW.    ir^e  StuderUif  Serie» 
of  Manuah,  page  14. 

PRINCIPLES  OF  TREATMENT.    In  one  octavo  volume  of  625  pages,    (loth. 


$3.75,  net. 

BRYANT  (THOMAS).  THE  PRACTICE  OF  SURGERY.  Fourth  American 
from  the  fourth  English  edition.     In  one  imperial  octavo  volume  of  1040  pages,  with  727 

illustrations.     Cloth,  $6.50;  leather,  $7.50. 

BURCHARD  (HENRY  H.).  DENTAL  PATHOLOGY  AND  THERAPEUTICS, 
INCLUDING  PHARMACOLOGY.     Handsome  octavo,  575  pages,  with  400  illoa- 

tratious.     Cloth,  $5  ;   leather,  $6,  net. 

BURNETT  (CHARLES  H.i.  THE  EAR:  ITS  ANATOMY,  PHYSIOLOOY 
AND  DISEASES.  A.  Practical  Treatise  for  the  Use  of  Students  and  Practitioners. 
Second  edition.     8vo.,  5,S0  pages,  with   107  illustrations.     Cloth,  $4  ;  leather,  $5. 

CARTER  (R.  BRUDENELLi  AND  FROST  W.  ADAMS i.  OPHTHALMIC 
SURGERY.  In  one  pocket-size  12rao.  volume  of  559  pages,  with  91  engravings  and 
one  plate.     Cloth,  $2.25,     See  Series  of  Clinical  MnnnaJn,  page  13. 

CASPARI  CHARLES,  JR.).  A  TREATISE  ON  PHARMACY.  For  StudenU 
and  Pharmacists.  Second  e<lition.  Revised  and  enlarged.  In  one  han<ls<>me  (x-tavo 
volume  of  732  pages,  with  327  illnstrations.     Cloth,  $4.25,  nrt, 

CHAPMAN  (HENRY  C).  A  TREATISE  ON  HUMAN  PHYSIOLOGY. 
Second  e<iition.  In  one  octavo  volume  of  921  pages,  with  596  illustrations.  Cloth, 
$4.25 ;  leather,  $.5.25,  net. 

Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Avenue. 


LEA    BROTHERS    &    CO.'S    PUBLICATIONS. 


CHARLES  (T,  CRANSTOUN).  THE  ELEMENTS  OF  PHYSIOLOGICAL 
AND  PATHOLOGICAL  CHEMISTRY.  In  one  handsome  octavo  volume  of  451 
pages,  with  38  engravings  and  1  colored  plate.     Cloth,  |3.50. 

CHEYNE  (W.WATSON)  AND  BURGHARD  (F.  F.).  SURGICAL  TREAT- 
MENT. In  seven  octavo  cloth  bound  volumes,  illustrated.  Volume  I,  299  pages  and  66 
engravings;  $3.00,  net.  Volume  II,  3S2  pages,  141  engravings;  |4.00,  net.  Volume 
III,  300  pages,  100  engravings;  $3.50,  net.  Volume  IV,  3><3  pages,  138  engravings; 
$3.75,  net.  Volume  V,  482  pages,  145  engravings ;  $5.00,  net.  Vol.  VI,  498  pages,  124 
engravings  ;  $5.00,  net.     Volume  VII,  in  Press. 

CLARKE  (W.  B.)  AND  LOCKWOOD  (C.  B.).  THE  DISSECTOR'S  MANUAL. 
In  one  12mo.  volume  of  396  pages,  with  49  engravings.  Cloth,  $1.50.  See  Students'  Series 
of  Manuals,  page  14. 

CLELAND  (JOHN).  A  DIRECTORY  FOR  THE  DISSECTION  OF  THE 
HUMAN  BODY.     In  one  12mo.  volume  of  178  pages.     Cloth,  $1.25. 

CLINICAL  MANUALS.     See  Series  of  Clinical  Manuals,  page  13. 

CLOUSTON  (THOMAS  S.).  CLINICAL  LECTURES  ON  MENTAL  DIS- 
EASES. New  (5th)  edition.  Crown  8vo.,  of  736  pages  with  19  colored  plates.  Cloth, 
$4.25,  net. 

gj^r  Folsom's  Abstract  of  Laws  of  U.  S.  on  Custody  of  Insane,  octavo,  $1.50,  is  sold  in 
conjunction  with  Clomton  on  Mental  Diseases  for  $5.00,  net,  for  the  two  works. 

CLOWES  (FRANK).  AN  ELEMENTARY  TREATISE  ON  PRACTICAL 
CHEMISTRY  AND  QUALITATIVE  INORGANIC  ANALYSIS.  From  the 
fourth  English  edition.    In  one  handsome  12mo.  volume  of  387  pages,  with  55  engravings. 

COAKLEY  (CORNELIUS  G.).  THE  DIAGNOSIS  AND  TREATMENT  OF 
DISEASES  OF  THE  NOSE,  THROAT,  NASO-PHARYNX  AND  TRACHEA. 
Second  edition.  In  one  12mo.  volume  of  556  pages,  with  103  engravings,  and  4  colored 
plates.     Cloth,  $2.75,  net. 

COATS  (JOSEPH).  A  TREATISE  ON  PATHOLOGY.  In  one  volume  of  829 
pages,  with  339  engravings.     Cloth,  $5.50 ;  leather,  $6.50. 

COLEMAN  (ALFRED).  A  MANUAL  OF  DENTAL  SURGERY  AND  PATH- 
OLOGY.    Octavo,  412  pages,  with  331  engravings.     Cloth,  $3.25. 

COLLINS  (C.  P.).    A   POCKET  TEXT-BOOK  OF  MEDICAL  DIAGNOSIS. 

12mo.  of  about  350  pages.     Shorthj. 

COLLINS  (H.  D.)  AND  ROCKWELL  (W.  H.,  JR.).  A  POCKET  TEXT- 
BOOK OF  PHYSIOLOGY.  12mo.,  of  316  pages,  with  153  illustrations.  Cloth, 
$1.50,  net;  flexible  red  leather,  $2.00,  net. 

CONDIE  (D.  FRANCIS).  A  PRACTICAL  TREATISE  ON  THE  DISEASES 
OF  CHILDREN.     Sixth  edition.     8vo.  719  pages.     Cloth,  $5.25;  leather,  $6.25. 

CORNIL  (V.).  SYPHILIS:  ITS  MORBID  ANATOMY,  DIAGNOSIS  AND 
TREATMENT.  Translated,  by  J.  Henry  C.  Simes,  M.D.,  and  J,  William  White, 
M.D.     8vo.  461  pages,  with  84  illustrations.     Cloth,  $3.75. 

CROCKETT  (M.  A.).  A  POCKET  TEXT-BOOK  OF  DISEASES  OF 
WOMEN.  12mo.  of  308  pages,  with  107  illustrations.  Cloth,  $1.50,  net.  Flexible 
Red  Leather,  $2.00,  net. 

CROOK  (JAMES  K.).  MINERAL  WATERS  OF  UNITED  STATES.  Octnvo, 
574  pages.     Cloth,  $3.50,  ne^ 


Philadelphia,  706,  708  and  710  Sansom  St. — New  York,  111  Fifth  Avenue. 


LEA    BROTHERS    &     CO.'S    PUBLICATIONS. 


CULBRETH  (DAVID  M.  E.).    MATERIA  MEDICA  AND  PHARMACOLOGY. 

Secoiid  ediiioii.      in  une  liandsome  (K-lavo  volume  of  >i'^\   pages',  with  -104  engravings. 
Cloth,  $4.50,  ui'A. 

CUSHNY    (ARTHUR    R.)     A    TEXT-BOOK   OF   PHARMACOLOGY   AND 
THKRAPhl   TK'S.     Second    edition.     Octavo   of  732    pages,    with    47    illustrations. 

DALTON   {JOHN   C).    A  TREATISE  ON  HUMAN  PHYSIOLOGY.    Seventh 
edition,  thoroughly  revised.  Octavo  of  722  pages, with  252  engravingB.  Cloth,  $5;  Ieather,$d. 

DOCTRINES  OF  THE  CIRCULATION  OF  THE  BLOOD.     In  one  hand- 


some 12mo.  volume  of  293  pages.     Cloth,  $2. 

DAVENPORT     F.  H.  l.      DISEASES    OF    WOMEN.     A    Manual   of  Gynecology. 

Pur  llif  u.-e  of  StudtnLs  and  General   I'raciirioners.     I'nurili  edition.     12mo..   1"2  paces 
and  l-'tt  engravings.     Cloth,  $1.75,  net. 

DAVIS  (F.H.).  LECTURES  ON  CLINICAL  MEDICINE.  Second  edition.  In 
one  lliiiio.  vohiaie  of  287  pages.     Cloth,  $1.75. 

DAVIS  EDWARD  P.).  A  TREATISE  ON  OBSTETRICS.  For  Students  and 
Prartitioners.  In  one  very  handsome  octavo  volume  of  54*)  pages,  with  217  en^rravings, 
and  30  full-page  plates  in  colors  and  monochrome.     Cloth,  $5;  leather,  $6. 

DE  LA  BECHE'S  GEOLOGICAL  OBSER  VER.  In  one  large  octavo  vuiunie  mi  700 
pages,  witii  oUO  engravings.     Cloth,  $4. 

DENNIS  FREDERIC  S.  i  AND  BILLINGS  JOHN  S.).  A  SYSTEM  OF 
Si'Ri'EIiY.  Iti  (  iintriliution-  liv  Aniurican  Author-.  In  four  very  handsome  octavo 
volumes,  containing  3052  pages,  with  1585  engravings,  and  45  full-page  plates  in  colors 
and  monochrome.  Per  volume,  cloth,  $6;  leather,  $7;  half  Morocco,  gilt  back  and 
top,  $M.50.     /•'//•  tidh:  bij  suhncription  only.     Full  prospectus  free. 

DERCUM  (FRANCIS  X.).  A  MANU.IL  OF  MENTAL  DISEASES.  Octavo, 
about  350  pages  with  many  engravings.     Shortly. 

Editor.     A    TEXT-BOOK    ON   NERVOUS  DISEASES.      By    American 

Authors.     In  one  han(W)me  octavo  volume  of  1054  pages,  with  341  engravings  and  7 
colored  plates,     (loth,  ^i);  leather,  $7,  net. 

DE  SCHWEIIHTZ  GEORGE  E.).  THE  TOXIC  AMBLYOPIAS;  THEIR 
CLASSIFICATION,  HISTORY,  SYMPTOMS,  PATHOLOGY  AND  TREAT- 
MENT. Very  handsome  octavo,  240  pages,  46  engravings,  and  9  full-page  plates  Ln 
col(.r<.     Limited  edition,  de  luxe  binding,  §4,  net. 

DRAPER  I  JOHN  C. ) .  MEDICA  L  PHYSICS.  A  Text-book  for  Students  and  Prac- 
titioners of  Medicine.     Octavo  of  734  pages,  with  376  engravings.     Cloth,  $4. 

DRUITT  (ROBERT).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURGERY.  From  the  twelfth  London  edition,  edited  by  Stanley  Boyd,  F.K.C.S. 
Larf,'e  oitavo,  '.tt)5  papes,  with  373  engravings.     Cloth,  $4  ;  leather,  $5. 

DUAiraf ALEXANDER*.  A  DICTIONARY  OF  MEDICINE  AND  THE 
ALLIED  SCIENCES.  Comprising  the  Pronunciation,  Derivation  and  Full  Explan- 
ation of  Medical,  Dental,  Pharmaceutical  and  N'eterinary  Terms.  Together  with  much 
Collateral  Descriptive  Matter,  Numerous  Tables,  etc.  Third  edition.  Scjuare  octavo 
volume  of  652  pages  with  8  colored  plates  and  thumb  index.  Cloth,  f3.00,  net;  limp 
leather,  $4.00,  net. 

DUDLEY  (E.G.).  A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  GYNECOLOGY.  For  Students  and  Practitioners.  Second  edition.  In  one 
very  handsome  octavo  volume  of  717  pages,  with  453  engravings,  of  which  47  are 
colored,  and  8  full  page  plates  in  colors  and  monochrome.  Cloth,  $5.00,  net;  leather, 
$6.00,  net  ;  half  morocco,  $6.50,  net. 

DUNCAN     J.  MATTHEWS!.     CLINICAL  LECTURES  ON  THE  DISEASES 

OF    WOMhW.     in  t.ne  0(  tavo  volume  of  175  pages.     Cloth,  $1.50. 

Philadelphia,  706.  708  and  710  Sansom  St.— Mew  York,  111  Fifth  Avenue. 


6  LEA    BROTHERS    &     CO.'S    PUBLICATIONS. 

DUNGLISON  (ROBLEY).  A  DICTIONARY  OF  MEDICAL  SCIENCE.  Con- 
taining a  full  Explanation  of  the  Various  Subjects  and  Terras  of  Anatomy,  Physiology, 
Medical  Chemistry,  Pharmacy,  Pharmacology,  Therapeutics,  Medicine,  Hygiene,  Dietetics. 
Pathology,  Surgery,  Ophthalmology,  Otology,  Laryngology,  Dermatology,  Gynecology, 
Obstetrics,  Pediatrics,  Medical  Jurisprudence,  Dentistry,  Veterinary  Science,  etc.,  etc. 
By  RoBLEY  DuNGLisoN,  M.D.,  LL.I3.,  late  Professor  of  Institutes  of  Medicine  in  the 
Jefferson  Medical  College  of  Philadelphia.  Edited  by  Richard  J.  Dunglison,  A.M., 
M.D.  Twenty-second  edition,  thoroughly  revised  and  greatly  enlarged  and  improved, 
with  the  Pronunciation,  Accentuation  and  Derivation  of  the  Terms.  With  Appendix. 
Imperial  octavo  of  1350  pages,  with  thumb  letter  index.  Cloth,  $7.00,  net;  leather, 
$8.00,  net.     This  edition  contains  portrait  of  Dr.  Mobley  Dunglison. 

DUNHAM  (EDWARD  K.).  MORBID  AND  NORMAL  HISTOLOGY.  Octavo, 
450  pages,  with  360  illustrations.     Cloth,  $3.25,  net. 

NORMAL   HISTOLOGY.     Second    edition.      Octavo,    319    pages,    with    244 

illustrations.     Cloth,  $2.50,  net. 

ECKLEY  (WILLIAM  T.l.  .1  GUIDE  TO  DISSECTION  OF  THE  HUMAN 
Body,     octavo,  about  450  pages,  richly  illustrated  in  black  and  colors.     In  Press. 

REGIONAL  ANATOMY  OF  THE  HEAD  AND  NECK  FOR  STUDENTS 

AND  PRACTITIONERS.     Octavo,  240  pages,  with  36  engravings  and  20  plates  in 
black  and  colors.     Cloth,  $2.50,  net. 

EDES  (ROBERT  T.).  TEXT-ROOK  OF  THERAPEUTICS  AND  MATERIA 
MEDIC  A.     In  one  8vo.  volume  of  544  pages.     Cloth,  $3.50;  leather,  $4.50. 

EDIS  (ARTHUR  W.).  DISEASES  OF  WOMEN.  8vo.,  576  pages,  with  148 
engravings.     Cloth,  $3  ;  leather,  $4. 

EGBERT  (SENECA).  HYGIENE  AND  SANITATION.  Second  edition.  In 
one  12mo.  volume  of  427  pages,  with  77  illustrations.     Cloth,  $2.25,  net. 

ELLIS  (GEORGE  VINER).  DEMONSTRATIONS  IN  ANATOMY.  Eighth 
edition.     Octavo,  716  pages,  with  249  engravings.     Cloth,  $4.25;  leather,  $5.25. 

EMMET  (THOMAS  ADDIS).  THE  PRINCIPLES  AND  PRACTICE  OF 
O  YNjECOLOGY.  For  the  use  of  Students  and  Practitioners.  Third  edition,  enlarged 
and  revised.     8vo.  of  880  pages,  with  150  original  engravings.     Cloth,  $5 ;  leather,  $6. 

ERICHSEN  (JOHN  E.).  THE  SCIENCE  AND  ART  OF  SURGERY.  From 
the  eighth  enlarged  and  revised  London  edition.  In  two  large  octavo  volumes  containing 
2316  pages,  with  984  engravings.     Cloth,  $9;  leather,  $11. 

ESSIG  (CHARLES  J.).  PROSTHETIC  DENTISTRY.  Second  Edition.  See 
American  'lezt-books  of  Dentistry,  page  2. 

DENTAL    METALLURGY.      Fourth   edition.      12mo.    277   pages  with    143 

engravings.     Cloth,  $1.75,  net. 

EVANS  (DAVID  J.).     A  POCKET  TEXT-BOOK  OF  OBSTETRICS.     12mo. 

of  409  i)ages,  with  148  illu.strations.     Cloth,  $1.75,  net;  limp  leather,  $2.25,  net. 

EWING  (JAMES).  A  PRACTICAL  TREATISE  ON  THE  BLOOD.  Octavo, 
432  pages,  with  30  engravings  and  14  full-page  colored  i)lates.     Cloth,     $3.-50,  net. 

EARQUHARSON  (ROBERT).  A  GUIDE  TO  THERAPEUTICS.  Fourth 
edition,  revised  by  Frank  Woodbury,  M.D.     12mo.,  581  pages.     Cloth,  $2.50. 

FIELD  (GEORGE  P.).  A  MANUAL  OF  DISEASES  OF  THE  EAR.  Fourth 
edition.     Octavo,  391  pages,  with  73  engravings  and  21  colored  plates.     Cloth,  $3.75. 

FINOLEY  (PALMER  D.).  A  TREATISE  ON  GYNAECOLOGICAL  DIAG- 
NOSIS.    Octavo,  about  (500  pages,  richly  illustrated.     Shortly. 

FLINT  (AUSTIN).  A  TREATISE  ON  THE  PRINCIPLES  AND  PRACTICE 
OF  MEDICINE.  Seventh  edition,  thoroughly  revised  by  Frederick  P.  Henry,  M.D. 
In  one  large  8vo.  volume  of  1143  pages,  with  engravings.     Cloth,  $5;  leather,  $6. 

A  MANUAL  OF  AUSCULTATION  AND  PERCUSSION;  of  the  Physi- 
cal Diagnosis  of  Diseases  of  the  Lungs  and  Heart,  and  of  Thoracic  Aneurism.  Fifth 
edition,  revised  by  James  C.  Wilson,  M.D.  In  one  handsome  12mo.  volume  of  274 
pages,  with  12  engravings. 


Philadelphia,  706,  708  and  710  Sansom  St— New  York,  111  Fifth  Avenue. 


LEA     BROTHERS    &     CO.'S    PUBLICATIONS.  7 

A  PRACTICAL  TREATISE  ON  THE  DlA(;S(JSIS  AND  TREAT- 
MENT OF  DISEASES  OF  THE  HEART.  Second  edition,  enlarged.  In  one 
octavo  volume  of  550  paK&s.     Cloth,  ^4. 

MEDICAL  ESSA  YS.     In  one  12mo.  volume  of  210  pages.     Cloth,  $1.38. 


FLINT  (AUSTIN).  A  PRACTICAL  TREATISE  ON  THE  PHYSICAL  EX- 
PLORATION OF  THE  CHEST,  AND  THE  DIAGNOSIS  OF  DISEASES 
AFFECTING  THE  RES P IRA  TOR  Y  ORGANS.  Second  and  revised  edition.  In 
one  octavo  volume  of  591  |>age'^.     ('lf)th,  ^4.50. 

ON  PHTHISIS :  ITS  MORBID  A NA  TOMY,  ETIOLOG  Y,  ETC.     A  Series 

nf  Clinical  Lectures.     In  one  8vo.  volume  of  442  pages.     (Jloth,  $3.50. 

FOLSOM  (C.  F.).  AN  ABSTRACT  OF  STATUTES  OF  U.  S.  ON  CUSTODY 
OF  THE  fNSANE.  In  one  8vo.  volume  of  108  pages.  Cloth,  $1.50.  With  aousUm 
on  Mental  />(>ert.scs  (see  page  4),  at  $5.00,  net,  for  the  two  works. 

FORMULARY,  THE   NATIONAL.     See  Stilli;  MaiKh  .t  Cd^iHiri'H  National  Di^penta 

lorii,  page  14. 

FORMULARY,  POCKET,     l^iurlh  edition.     See  page  1.     $1.50,  «<•/. 

FOSTER  (MICHAEL).  .1  TEXT-BOOK  OF  PHYSIOLOGY.  Sixth  and  revi.^d 
American  from  liie  si.xth  English  edition.  In  one  large  octavo  volume  of  923  pages, 
with  257  illustration-;.     Cloth,  $4.50;  leather,  $5.50. 

FOTHERGILL  (J.  MILNERK     HAND-BOOK  OF  TREATMENT.    Third  edition. 

Oftav.),  (it;4  pages.     Cloth,  $3.75;  leather,  $4.75. 

FOWNES  (GEORGE).  A  MANUAL  OF  ELEMENTARY  CHEMISTRY  (IN- 
ORGANIC AND  ORGA.NIC).  Twelfth  edition.  Embodying  Watts'  P/(i/;»icn/  an<y 
Inorqanic  C/ievii,flry.  In  one  royal  12mo.  volume  of  lOtil  pages,  with  168  engravings,  and 
1  colored  plate.     Cloth,  $2.75 ;  'leather,  $3.25. 

FRANKLAND  (E.)  AND  JAPP  (F.  R.).     INORGANIC  CHEMISTRY.    Octavo, 

')77  pages,  with  51  engravings  and  2  plates.     Cloth,  $3.76;  leather,  $4.75. 

FULLER   (EUGENE  I.     DISORDERS  OF  THE  SEXUAL  ORGANS  IN  THE 

MALE.     <  ),tav(i,   238  t)ages,  with  25  engravings  and  8  plates.     Cloth,  $2. 

GALLAUDET    ^BERN    B.^.       .4    POCKET    TEXT-BOOK    OF   SURGERY. 

12iii<>.  of  ahtiut  4(11)  jiau'e-;,  with  many  illustrations.     In   PreSK. 

QANT  (FREDERICK  JAMES  i.  THE  STUDENT'S  SURGERY.  A  Multum  in 
Parvo.     hi  one  sipiare  octavo  volume  of  845  pages,  with  159  engravings.     Cloth,  $3.75. 

GAYLORD  I  HARVEY  R.  i  AND  ASCHOFF  (LUDWIGi.     THE  PRINCIPLES 

OF  iWTIloLOCK'AL  HISTOLO(iY.  With  an  introductory  note  by  William  H. 
Wllch,  M.l).  In  one  very  hand.-ome  (piarto  volume  of  354  pages,  with  81  engravings 
in  the  text  and  40  full-page  plates.     Cloth,  $7.50,  net. 

GERRISH  (FREDERIC  H.).      A    TEXT-BOOK  OF  ANATOMY.     By   American 

Authors.      Edited  Ky  I'rkdkuic  II.  OKURisn,  M.D.  In  one  imp.  octavo  volume  of  915 

l)ages,  with  li.')0  illustrations  in  black  and  colors.  Cloth,  $0.50;  fle.Tible  water-proof, 
$7  ;  sheep,  •'?7. •')(),  net. 

GIBBES    (HENEAGE).     PRACTICAL   PATHOLOGY  AND   MORBID    HIS- 

TOIjOG  Y.  ( )(tavo  of  314  pages,  with  00  illustrations,  mostly  photographic.  Cloth,  $2.75. 
GRAY  (HENRY).  ANA  TOMY,  DESCRfPTlVE  AND  SURGICA  L.  New  (15th) 
edition  thoroughly  -evised.  In  one  imperial  octavo  volume  of  1249  pages  with  7S0  large 
and  elaborate  engravings.  Price  with  illustrations  in  colors,  cloth.  $(5.25,  net;  leather, 
$7.25,  net.     Price,  with  illustrations  in  black,  cloth,  $5.50;  leather,  $('). 50,  nrt. 

GRAYSON    (CHARLES    P.).      DfSEA^'ES   OF   THE    THRO.AT,    NOSE,    4  VZ) 

I SSO(  r.  I  TED  .  I  I'FFf  riOXS  or  the  E.  I  a*,  in  one  hnndsome  octavo  volume  of 
iibout  5(10  piires,  with  129  engravings  and  S  plates  in  colors  and  monochrome.     In  I'rnv. 

GREEN  <T.  HENRY).  ^.V  INTRODUCTION  TO  PATHOLOGY  AND  MOR- 
BID ANATOM Y.  New  (9th)  American  from  ninth  and  roviseil  English  edition. 
Oct.  5(!5  pages,  with  339  engravings  and  4  colored  plates.     Cloth,  $3.25,  net. 

GREENE  (WILLIAM  H.).     A   MANUAL  OF  MEDICAL  CHEMrSTRY.     For 

tlie  Cse  of  Students.  Hased  upon  Bowman'.-^  Medienl  Chemij<tnj.  In  one  12mo.  volume 
of  310  i)ages,  with  74  illustration.s.     Cloth,  $1.75. 

Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Avenue. 


LEA    BROTHERS    &    CO.'S    PUBLICATIONS. 


GRINDON  (JOSEPH).     A    POCKET   TEXT-BOOK   OF  SKIN  DISEASES. 

12mo.  of  350  pages,  with  many  illustrations.      In  Press. 

GROSS  (SAMUEL  D.).  A  PRACTICAL  TREATISE  ON  THE  DISEASES, 
INJURIES  AND  MALFORMATIONS  OF  THE  URINARY  BLADDER, 
THE  PROSTATE  GLAND  AND  THE  URETHRA.  Third  edition,  revised  by 
Samuel  W.  Gross,  M.D.     Octavo  of  574  pages,  with  170  illustrations.     Cloth,  $4.50. 

HABERSHON  (S.  0.).  ON  THE  DISEASES  OF  THE  ABDOMEN.  Second 
American  from  the  third  English  edition.  Octavo,  554  pages,  with  11  engravings. 
Cloth,  $3.50. 

HALL  (WINFIELD  S.).  TEXT-BOOK  OF  PHYSIOLOGY.  Octavo,  672  pages, 
with  343  engravings  and  6  colored  plates;     Cloth,  $4.00,  net;   leather,  $5.00,  net. 

HAMILTON  ( ALLAN  McLANE ) .  NER  VO  US  DISEASES,  THEIR  DESCRIP- 
TION AND  TREATMENT.  Second  and  revised  edition.  In  one  octavo  volume  of 
598  pages,  with  72  engravings.     Cloth,  $4. 

HARD  AW  AY   (W.   A.).      MANUAL    OF  SKIN   DISEASES.      Second  edition. 

12mo.,  560  pages  with  40  illustrations  and  2  colored  plates.     Cloth,  $2.25,  net. 

HARE  (HOBART  AMORY).  A  TEXT-BOOK  OF  PRACTICAL  THERAPEU- 
TICS, with  Special  Keference  to  the  Application  of  Remedial  Measures  to  Disease  and 
their  Employment  upon  a  Rational  Ba?is.  With  articles  on  various  subjects  by  well-known 
specialists.  Ninth  revised  edition.  In  one  octavo  volume  of  851  pages,  with  105  engrav- 
ings and  4  colored  plates.    Cloth,  $4. 00,  wei ;  leather,  $.5. 00,  7ie< ;  half  morocco,  $5.50,  net. 

PRACTICAL  DIAGNOSIS.  The  Use  of  Symptoms  in  the  Diagnosis  of  Dis- 
ease. Fourth  edition,  revised  and  enlarged.  In  one  octavo  volume  of  623  pages,  with 
205  engravings,  and  14  fuD-page  plates.     Cloth,  $5,  net;  half  morocco,  $6.50,  net. 

Editor.     A  SYSTE3I  OF  PRACTICAL  THERAPEUTICS.     By  American 


and  Foreign  Authors.  In  a  series  of  contributions  by  eminent  practitioners.  Second 
edition.  In  three  large  octavo  volumes  containing  2593  pages,  with  457  engravings  and 
26  full-page  plates.  Price  per  volume,  cloth,  $5.00,  net;  leather,  $G.OO,  net;  half 
morocco,  $7.00,  net.  For  sale  by  sithscription  only.  Full  prospectus  free  on  application 
to  the  publishers. 

ON  THE  MEDICAL  COMPLICATIONS  AND  SEQUELS  OF  TYPHOID 


FEVER.    Octavo,  276  pages,  21  engravings,  and2  full-page  plates.     Cloth,  $2.40,  net. 

HARRINGTON  (CHARLES).  .1  TREATISE  ON  PRACTICAL  HYGIENE. 
Handsome  octavo  of  721  pages,  with  105  engravings  and  12  plates  in  colors  and  mono- 
chrome.    Cloth,  $4.25,  net. 

HARTSHORNE  (HENRY).  ESSENTIALS  OF  MEDICINE.  Fifth  edition. 
12mo.,  669  pages,  with  144  engravings.     Cloth,  $2.75. 

A   HANDBOOK  OF  ANATOMY  AND   PHYSIOLOGY.     In  one  12mo. 

volume  of  310  pages,  with  220  engravings.     Cloth,  $1.75. 

A  CONSPECTUS  OF  THE  MEDICAL  SCIENCES.     Comprising  Manuals 


of  Anatomy,  Physiology,  Chemistry,  Materia  Medica,  Practice  of  Medicine,  Surgery  and 
Obstetrics.  Second  edition.  In  one  royal  12mo.  volume  of  1028  pages,  with  477  illus- 
trations.    Cloth,  $4.25;  leather,  $5. 

HAYDEN  (JAMES  R.).  A  POCKET  TEXT-BOOK  OF  VENEREAL  DIS- 
EASES. Third  edition.  In  one  12mo.  volume  of  304  pages,  with  66  engravings. 
Cloth,  $1.75,  net.  ;  Flexible  red  leather,  $2.25,  net.  See  Lea's  series  of  Pocket  Text- 
Books,  page  12. 

HAYEM  (GEORGES)  AND  HARE  (H.  A.).  PHYSICAL  AND  NATURAL 
THERAPEUTICS.  The  Remedial  Use  of  Heat,  Electricity,  Modifications  of  Atmos- 
pheric Pressure,  Climates  and  Mineral  Waters.  Edited  by  Prof.  H.  A.  Hare,  M.D. 
In  one  octavo  volume  of  414  pages,  with  113  engravings.     Cloth,  $3. 

HERMAN  (G.  ERNEST).  FIRST  LINES  IN  MIDWIFERY.  12mo.,  198  pages, 
with  80  engravings.     Cloth,  $1.25.     See  Students'  Series  of  Manuals,  page  14. 

HERMANN  (L.).  EXPERIMENTAL  PHARMACOLOGY.  A  Handbook  of  the 
Methods  for  Determining  the  Physiological  Actions  of  Drugs.  Translated  by  Robert 
Meade  Smith,  M.D.     In  one  12mo.  vol.  of  199  pages,  with  32  engravings.     Cloth,  $1.50. 


Philadelphia,  706,  708  and  710  Sansom  St. — flew  York,  111  Fifth  Avenue. 


LEA     BROTHERS    &     CO.S     PUBLICATIONS.  9 

HERRICK  (JAMES  B.).  A  HANDBOOK  OF  DIAGNOSIS.  In  one  handsome 
Vlu\(>.   volume  of    Vl'J  ijaget*,  with  80  engraving  and  2  colored  plates.     Cloth,  $2.50. 

HERTER    (C.   A.).      LECTURES    ON    CHEMICAL    PATHOLOGY.     In  one 

12  ino.  voluinc  of  lot  j)ages.     Cloth,  $1.75,  net. 

HILL  ( BERKELEY ).    SYPHILIS  AND  LOCAL  CONTAOIO US  DISORDERS. 

Ill  one  .Svo.  vdIuiiio  of  479  pages.     Cloth,  $3.25. 

HILLIER  (THOMAS).     A  HANDBOOK  OF  SKIN  DISEASES.    Second  edition. 

In  one  roval  12iiio.  volume  of  ;■!■').■>  jiatrcs.  with  twn  plati-s.     Cloth,  $2.25. 

HIRST  (BARTON  C.i  AND  PIERSOL  GEORGE  A.).  HUMAN  MONSTROS- 
ITIES. Magniliceut  filio,  containing  220  i)agt-s  of  text  and  illustrated  with  123  engrav- 
ings and  39  large  pliolograpliic  [jlates  from  nature.      In  four  parts,  [>rice  each,  $5. 

HOBLYN  RICHARD  D.).  A  DICTIONARY  OF  THE  TERMS  USED  IN 
MEDICINE  AND  THE  COLLATERAL  SCIENCES.  Thirteenth  edition.  In 
one  12mo.  volume  of  845  pages.     Cloth,  $3.00,  net. 

HODGE  (HUGH  L.).     ON  DISEASES  OF  WOMEN.     Second  and  revised  edition. 

Hvo. .  519  pages,  with  illustrations.     Cloth,  $4.50. 

HOFFMANN  (FREDERICK)  AND  POWER  (FREDERICK  B.).    A  MANUAL 

OF  CHEMICAL  ANA  LYSIS, iis  .\p[)lie(l  to  the  Ivxaminatiun  of  Medicinal  Chemicals 
and  their  Preparations.  Third  edition,  entirely  rewritten  and  much  enlarged.  In  one 
hand.sorae  octavo  volume  of  621  pages,  with  179  engravings.     Cloth,  $4.25. 

HOLMES  (TIMOTHY).  A  TREATISE  ON  SURGERY.  Its  Principles  and 
Practice.  I'rom  the  (ifth  English  edition.  Edited  by  T.  Pickering  Pick,  F.R.C.S. 
Octavo,  1008  pages,  with  428  engravings.     Cloth,  $6;  leather,  $7. 

A  SYSTEM   OF  SURGERY.     With  additions  by  various  American  authors. 

Edited  by  John  H.  P.\CKARr),  M.D.  In  three  8vo.  volumes  containing  3137  page««, 
with  979  engravings  and   13  lithographic  plates.     Per  volume,  cloth,  $6. 

HUDSON    (A.).     LECTURES  ON  THE  STUDY  OF  FEVER.     In  one  octavo 

volume  of  o08  pages.     Cloth,  $2.50. 

HUNTINGTON  (GEORGE  S.).  ABDOMINAL  ANATOMY.  In  one  imperial 
quarto  volume,  with  about  '-'.'O  pages  of  text  and  about  300  full-page  plates.     In  Prej^s. 

HYDE  (JAMES  NEVINS)  AND  MONTGOMERY  FRANK  H.  i.  A  PRAC- 
TICAL TREATISE  ON  DISEASES  OF  THE  SKIN.  Sixth  edition,  thoroughly 
revised.  Octavo,  832  pages,  with  107  engravings  and  27  fuU-paire  plates,  9  of  which 
are  colored.     Cloth.  $4.50,  iff;  leather,  $5.50,  ml;  half  morocco,  $tJ.(M),  nrt. 

JACKSON  '  GEORGE  THOMAS  i .  THE  READ  Y-REFERENCE  HA NDB 0 OK 
OF  DISEASES  OF  THE  SKIN.  Fourth  edition.  12mo.  volume  of  617  pages, 
with  S2  engravings,  and  3  colored  plates.    Cloth,  $2.75,  net. 

JAMIESON  (W.  ALLAN).     DISEASES  OF  THE  SKIN.    Third  edition.     Octavo, 

656  pages,  with  1  engraving  and  9  double-page  chrorao-lithographic  plates.     Cloth,  $6. 

JEWETT    (CHARLES).      ESSENTIALS    OF    OBSTETRICS.      Second    edition. 

rjino.,  'A^')   i>ages,   with  80  engravings  and  5  colored  plates.     Cloth,     $2.25,  net. 

THE  PRACTICE  OF  OBSTETRICS.     IJy  .\merican  .\uthors.    Second  edition. 

One  octavo  volume  of  775  pages,  with  445  engnivings  in  black  and  colors,  and  35 
full-[iage  colored   plates.     Cloth,    $5.00;  leather,  $6.00;  half  morocco,  $6.50. 

JULER  (HENRY).  A  HANDBOOK  OF  OPHTHALMIC  SCIENCE  AND 
PRACTICE.  Second  edition.  In  one  octavo  volume  of  549  pages,  with  201  engrav- 
ings, 17  chromo-lithograjdiic  plates,  test-tvpes  of  Jaeger  and  Snellen,  and  Holmgren's 
Color-niiudness  Test.     Cloth,  $5.50;  leather,  $6.50. 

KIRK  (EDWARD  C).  OPERATIVE  DENTISTRY.  Second  edition.  See 
Ameriam   IVrt-hookn  of  Deiiti.itrj/,  page  2. 

KING  (A.  F.  A.).  A  MANUAL  OF  OBSTETRICS.  Eighth  edition.  In  one 
12mo.  volume  of  612  pages,  with  264  illustrations.     Clotk,  $2.50.  Del. 

KLEIN  (E.).     ELEMENTS  OF  HISTOLOGY.     Fifth  edition.     In  one  pocket-sire 
12mo.   volume  of  506  pages,  with  296  engravings.     Cloth,  |2.00,  net. 
See  Studentif'  Seriej<  of  ManutdA,  page  14. 


Philadelphia,  706,  708  and  710  Sansom  St.— Mew  York,  111  Fifth  Avenue. 


10  LEA    BROTHERS    &     CO:S    PUB  L/C  AT/0  MS. 


KOPLIK  (HENRY).     THE  DISEASES  OF  INFANCY  AND   CHILDHOOD. 

Octavo,  about  7U0  pages  with  168  engravings.     In  Press. 

LANDIS  (HENEY  G.).     THE  MANAGEMENT  OF  LABOR.    In  one  handsome 

12mo.  volume  of  329  pages,  with  28  illustrations.     Cloth,  $1.75. 

LA  ROCHE  (R.).  YELLOW  FEVER.  In  two  8vo.  volumes  of  1468  pages. 
Cloth,  §7. 

LAURENCE  (J.  Z.)  AND  MOON  ( ROBERT  C).     OPHTHALMIC  SURGERY. 

Second  edition.     Octavo,  227  pages,  with  66  engravings.     Cloth,  $2.75. 

LEA  (HENRY  C).  CHAPTERS  FROM  THE  RELIGIOUS  HISTORY  OF 
SPAIN;  CENSORSHIP  OF  THE  PRESS;  MYSTICS  AND  ILLUMINATI; 
THE  ENDEMONIADAS ;  EL  SANTO  NINO  DE  LA  GUARDIA;  BRI- 
ANDA  DE  BARDAXL     In  one  12mo.  volume  of  522  pages.     Cloth.  $2.50. 

A  HISTORY  OF  AURICULAR  CONFESSION  AND  INDULGENCES 

IN  THE  LATIN  CHURCH.     In  three  octavo  volumes  of  about  500  pages  each. 
Per  volume,  cloth,  $3. 

THE  MORISCOS  OF  SPAIN:  THEIR  CONVERSION  AND  EXPULSION. 


In  one  royal  12mo.  volume  of  about  425  pages.     Extra  cloth,  $2.25,  net. 

STUDIES   IN  CHURCH  HISTORY.      New    edition.      12mo ,    605   pages. 


Cloth,  $2.50. 

SUPERSTITION  AND  FORCE;  ESSAYS  ON  THE  WAGER  OF  LAW, 


THE    WAGER    OF  BATTLE,    THE    ORDEAL   AND    TORTURE.      Fourth 
edition,  thoroughly  revised.     In  one  royal  12mo.  volume  of  629  pages.     Cloth.  $2.75. 

AN  HISTORICAL  SKETCH  OF  SACERDOTAL  CELIBACY  IN  THE 


CHRISTIAN  CHURCH.     Second  edition.     In  one  handsome  octavo  volume  of  685 
pages.     Cloth,  $4.50. 

LEA'S  SERIES  OF  MEDICAL  EPITOMES.  Covfring  the  entire  field  of  medicine 
and  surgery  in  twenty  convenient  volumes  of  about  250  pages  each,  amply  illustrated 
and  written  by  prominent  teachers  and  specialists.  Compendious,  authoritative  and 
modern.  Following  each  chapter  is  a  series  of  questions  which  will  be  found  convenient 
in  quizzing.     The  Series  is  constituted  as  follows  : 

1.  Hale's  Anatomy.  2.  Guenther's  Physiology.  3.  McGlannon's  Chemistry  and 
Physics.  4.  Kiepe's  Materia  Medica  and  Therapeutics.  5.  Dayton's  Practice  of  Med- 
icine. 6.  Ilollis's  Physical  Diagnosis.  7.  Arneill's  Clinical  Diagnosis  and  Urinalysis. 
8.  Nagle's  Nervous  and  Mental  Diseases.  9.  Wathen's  Histology.  10.  Stenhouse's 
Pathology.  11.  Archinard's  Bacteriology.  12.  Magee  and  .Johnson's  Surgery. 
13.  Veasey's  Ophthalmology.  14.  Brown  and  Ferguson's  Ear,  Nose  and  Throat. 
15.  Schmidt's  Genito-Urinary  and  Venereal  Diseases.  16.  Schalek's  Dermatology. 
17.  Pedersen's  Gynecology.  18.  Manton's  Obstetrics.  19.  Tuley's  Pediatrics. 
2(1.    Dwiglit"s  .rurisprudence  and  Toxicology. 

LE  FEVRE  (EGBERT).  A  TEXT-BOOK  OF  PHYSICAL  DIAGNOSIS.  In  one 
12mo.  volume  of  about  350  pages,  amply  illustrated.     In  Press. 

LONG  (ELI).  A  MANUAL  OF  DENTAL  MATERIA  MEDICA  AND 
THERAPEUTICS.     12mo.,  about  350  pages  with  many  engravings.     Shortly. 

LOOMIS  (ALFRED  L.)  AND  THOMPSON  (W.  GILMAN),  Editors.  A  SYS- 
TEM  OF  PR  A  OTICA  L  MEDICINE.  In  Contributions  by  Various  American  Authors. 
In  four  very  handsome  octavo  volumes  of  about  900  pages  each,  fully  illustrated  in  black 
and  colors.  Per  volume,  cloth,  $5 ;  leather,  $6 ;  half  Morocco,  $7.  For  sale  by  sub- 
scription only.     Full  prospectus  free  on   application. 

LYMAN  (HENRY  M.).  THE  PRACTICE  OF  MEDICINE.  In  one  very  hand 
some  octavo  volume  of  925  pages  with  170  engravings.     Cloth,  $4.75;  leather,  $5.75. 

LYONS  (ROBERT  D.).    A  TREATISE  ON  FEVER.     In  one  octavo  volume  of  362 

pages.     Cloth,  $2.25. 

MACKENZIE  (JOHN  NOLAND).  THE  DISEASES  OF  THE  NOSE  AND 
THROAT.     Octavo,  of  about  600  pages,  richly  illustrated.     Preparing. 

MAISCH  (JOHN  M.).  A  MANUAL  OF  ORGANIC  MATERIA  MEDICA. 
Seventh  edition,  thoroughly  revised  by  H.  C.  C.  Maisch.  Ph.G.,  Ph.D.  In  one  very 
handsome  12mo.  of  512  pages,  with  285  engravings.     Cloth,  $2.50,  net, 

Philadelphia,  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Avenue. 


f  f /«     BROTHERS    &     CO.' S    PUBLICATIONS.  11 

MALSBARY  (GEO.  E.).  A  POCKET  TEXT-BOOK  OF  THEORY  ASD 
I'RAOTIVE  OF  MEDICI M:.  12mo.  40'j  pages,  willi  a:>  illastrationj..  Cloth,  $1.75, 
ncl ;  flexible  red  leather,  $2.25,  net. 

MANUALS.  See  Student  Quiz  Series,  page  14,  StudenU  Sei-u-i  „/'  .V,ruu,ii..  (.ru--  11.  and 
Serien  of  Clinical  Mantiuls,  page  13. 

MARSH  (HOWARD).  DISEASES  OF  THE  JOINTS.  In  one  l-n.o.  vonuue  of 
4t),s  iia;,'e.-<,  with  *',1  en<jravings  and  a  colored  plate,     ("loth,  $2.     See  Series  of  Clinical 

i)/'(/n('//.v,  page  l.">. 

MARTIN  (EDWARD.)     SURGICAL   DIAGNOSIS.     <  »ne  12mo.   volume  of  400 

pages,  richly  ilhi.-trated.     Preparing. 

MARTIN  (WALTON  AND  ROCKWELL  W.  H.,  JR.*.  A  POCKET  TEXT- 
BOOK OF  CIlF.yiSTRV  AND  PHYSICS.  12ino.  360  pages,  with  137  illus- 
trations.    Cloth,  5^1.50,  uel ;  flexible  red  leather,  $2.00,  n<:/. 

MAY  (C.  H.).  DISEASES  OF  WOMEN.  Second  edition,  revised  by  I..  S.  Km-, 
M.l).      12ni()  ,  3t'>0  pages.  :U  engravings.     Cloth,  $1.75. 

MEDICAL  NEWS  POCKET  FORMULARY.    See  page  1.    $1.50,  net. 

MITCHELL  I  JOHN  K.i.  REMOTE  CONSEQUENCES  OF  INJURIES  OF 
NERV^ES  AND  THEIR  TREATMENT.  In  one  handsome  r2mo.  volume  of  239 
pages,  with  12  ilhi.strations.     Cloth  $1.7.5. 

MITCHELL     S.   WEIR).     CLINICAL   LESSONS   ON  NERVOUS  DISEASES. 

12ini).,  2',''.>  pages,  witi>  17  engravings  and  2  colored  plates.     Cloth,  $2.50. 

MORRIS  (MALCOLM).  DISEASES  OF  THE  SKIN.  Second  edition.  12mo., 
GUI   pages,  with   10  ehromo-lithographic  plates  and  2G  engravings.      Cloth,  $3.25,  mi. 

MULLER  (J.).     PRINCIPLES  OF  PHYSICS  AND  METEOROLOGY.     In  one 

large  8vo.  volume  of  623  pages,  with  538  engravings.     Cloth,  $4.50. 

MUSSER  (JOHN  H.).  A  PRACTICAL  TREATISE  ON  MEDICAL  DIAGNO- 
SIS, fur  Student-s  and  Phvsicians.  Fourth  edition.  Octavo,  1104  pages,  with  250  en- 
gravings and  49  full-page 'colored  plates.  Cloth,  $6.00  /  leather.  $7.00;  half  morocco, 
$7.50,  net. 

NATIONAL  DISPENSATORY.    See  StiUi;  Maisch  &  Campari,  page  14. 

NATIONAL    FORMULARY.      See  National  Dispensatory,  page  14. 

NATIONAL  MEDICAL  DICTIONARY.     See  Billings,  page  3. 

NETTLESHIP  (E.).  DISEASES  OF  THE  EYE.  Si.xth  American  from  sixth 
Englisli  edition.  Thoroughly  revised.  12nio.,  562  pages,  with  192  engravings.  5  colored 
plates,  test-types,  forinuhe  and  color-blindness  test.      Cloth,  $2.25,  nfi. 

NICHOLS  JOHN  B.  >  AND  VALE  (F.  P.).  A  POCKET  TEXT-BOOK  OF 
HISTOLOGY  AND  PATHOLOGY.  r2mo.  of  4.59  pages,  with  213  illustrations. 
Cloth,  $1.75,  net;  fle.tible  red  leather,  $2.25,  net. 

NORRIS  f WM.  T.)  AND  OLIVER  (CHAS.  A. •.     TEXT-BOOK  OF  OPHTHAL- 

MOLOO  Y.      In  cue  intavo  vnhiiuo  of  ijll   pages,  with  ;^"»7  engravings  and  5  colored 
plates.      ('K)th,  :^■') ;   leather,  $6. 

OWEN  (EDMUND).  SURGICAL  DISEASES  OF  CHILDREN.  In  one  Timo. 
volume  of  525  pages,  with  85  engravings  and  4  colored  plates.     Cloth,  $2.     See  Series  of 

Clinical  Manual.^,  page  13. 

PARK  (WILLIA.M  H.i.     BACTERIOLOGY  IN  MEDICfNE  AND  SURGERY. 

12ui  I.  6SS  pag.s,  with  87  en^ra/ings  in  bla^k  and  colors  and  2  colored  plate-.     Cloth, 
$.3.00.  net. 

PARK  (ROSWELLi.  Editor.  A  TREA  TISE  ON  SURGER  Y,  by  .\merican  Authors. 
For  Students  and  Practitioners  of  Surgery  and  Medicine.  Third  edition.  In  one 
large  octJivo  volume  of  140S  pages,  with  692  engravings  and  64  pl.ates.  Cloth,  $7.00/ 
leather,  $8.00,  net. 

Philadelphia,  706.  708  and  710  Sansom  St. — Mew  York,  111  Fifth  Avenue. 


12  LEA    BROTHERS    &     CO.' S    PUBLICATIONS. 

PARVIN  (THEOPHILUS).     THE  SCIENCE  AND  ART  OF  OBSTETRICS. 

Third  edition.     In  one  handsome  octavo  volume  of  677  pages,  with  267  engravings  and 
2  colored  plates.     Cloth,  $4.25;  leather,  $5.25. 

PEPPER'S  SYSTEM  OF  MEDICINE.    See  page  2. 

PEPPER  (A.  J.).  SURGICAL  PATHOLOGY.  In  one  12mo  volume  of  511  pages, 
with  81  engravings.     Cloth,  $2.     See  Stiulents'  Series  of  Manuals,  page  14. 

PICK  (T.  PICKERING).     FRACTURES  AND  DISLOCATIONS.     In  one  12mo. 

volume  of  530  pages,  with  93  engravings.    Cloth,  |2.    See  /Series  of  Clinical  Manuals,  p.  13. 

PLAYFAIR  (W.  S.).  THE  SCIENCE  AND  PRACTICE  OF  MIDWIFERY. 
Seventh  American  from  the  IS'inth  English  edition.  Octavo,  700  pages,  with  207  engrav- 
ings and  7  full  page  plates.     Cloth,  $3.75;  leather,  $4.75,  net. 

THE  SYSTEMATIC  TREATMENT  OF  NERVE  PROSTRATION  AND 


HYSTERIA.     In  one  12mo.  volume  of  97  pages.     Cloth,  $1. 

POLITZER  (ADAM).  A  TEXT-BOOK  OF  THE  DISEASES  OF  THE  EAR 
AND  ADJACENT  ORGANS.  Third  American  from  the  Fourth  German  edition. 
In  one  octavo  volume  of  748  pages,  with  330  original  engi-avings.     Preparing. 

POCKET  FORMULARY.     Fourth  edition.     See  page  1. 

POCKET  TEXT-BOOKS  Cover  the  entire  domain  of  medicine  in  sixteen  volumes  of 
350  to  525  pages  each,  written  by  teachers  in  leading  American  medical  colleges. 
Issued  under  the  editorial  supervision  of  Bern  B.  Gallaudet,  M.D.  ,  of  the  College  of 
Physicians  and  Surgeons,  New  York.  Thoroughly  modern  and  authoritative,  concise 
and  clear,  amply  illustrated  with  engravings  and  plates,  handsomely  printed  and 
bound.  The  series  is  constituted  as  follows :  Anatomy,  Physiology,  Chemistry  and 
Physics,  Histology  and  Pathology,  Materia  Medica,  Theiapeutics,  Medical  Pharmacy, 
Prescription  VN'riting  and  Medical  Latin,  Practice,  Diagnosis,  Is^ervous  and  Mental  Dis- 
eases, Surgery,  Venereal  Diseases,  Skin  Diseases,  Eye,  Ear,  Nose  and  Throat,  Obstetrics, 
Gynecology,  Diseases  of  Children,  Bacteriology.  For  further  details  see  under  respective 
authors  in  this  catalogue.     Special  circular  free  on  application. 

POTTS  (CHAS.  S.).  A  POCKET  TEXT-BOOK  OF  NERVOUS  AND 
MENTAL  DISEASES.  12mo.  of  455  pages,  with  88  illustrations.  Cloth,  $1.75,  net  ; 
flexible  red  leather,  $2.25,  net.     Lea's  Series  of  Pocket  Text-Books,  page  12. 

A    TEXT-BOOK    ON   MEDICINE   AND   SURGICAL   ELECTRICITY. 


Octavo,  about  S-'.O  pages,  amply  illustrated.     Shortly. 

POSEY  (W.  C.)  AND  WRIGHT  (JONATHAN).  A  TREATISE  ON  THE 
EYE,  NOSE,  THROAT  AND  EAR.  Octavo,  about  800  pages,  richly  illustrated 
in  black  and  colors.     In,  Press. 

PROGRESSIVE  MEDICINE.     See  page  1.     Per  annum,  $10.00. 

PURDY  (CHARLES  W.).  BRIGHT'S  DISEASE  AND  ALLIED  AFFEC- 
TIONS OF  THE  KIDNEY.  In  one  octavo  volume  of  288  pages,  with  18  engrav- 
ings.    Cloth,  $2. 

PYE-SMITH  (PHILIP  H.).  DISEASES  OF  THE  SKIN.  In  one  12mo.  volume 
of  407  pages,  with  28  illustrations,  18  of  which  are  colored.     Cloth,  $2. 

QUIZ  SERIES.     See  Students'  Quiz  Senes,  page  14. 

RALFE  (CHARLES  H.).  CLINICAL  CHEMISTRY.  In  one  12mo.  volume  of 
314  pages,  with  16  engravings.     Cloth,  $1.50.     See  Students'  Series  of  Manuals,  page  14. 

REMSEN  (IRA).  THE  PRINCIPLES  OF  THEORETICAL  CHEMISTRY. 
Fifth  edition,  thoroughly  revised.     In  one  12mo.  volume  of  326  pages.     Cloth,  $2. 

REYNOLDS  (EDWARD)  AND  NEWELL  (F.  S.).  MANUAL  OF  PRACTI- 
CAL OBSTETRICS.     Octavo,  about  600  pages,  richly  illustrated.     Shortly. 


Philadelphia,  706,  708  and  710  Sansom  St— New  York,  111  Fifth  Avenue. 


LEA     BROTHERS    &     CO.'S    PUBLICATIONS.  13 

RICHARDSON   t BENJAMIN   WARD;.     PREVENTIVE  MEDICINE.     Jn  one 

octavo  vcjlimie  of  72'.*  piigcM.     (loth,  $4. 

ROBERTS  (JOHN  B.).  THE  PRINCIPLES  AND  PRACTICE  OF  MODERN 
SURG ER  Y.  Second  edition.  In  one  octavo  volume  of  838  pages,  with  474  engravings 
and  S  plate-*;,     ("loth,  .$4.'2o,  net ;  leather,  $o.2o,  nc/. 

ROCKWELL  ( W.  H ..  Jr. ).      1  POCKET  TEXT- liO OK  oF  A  N  I  TOM  Y.     1 2mo., 

iihout   I'll!  |i:ii,'t'-;.  illustrated.      In   Pnnn. 

ROSS  ( JAMES  1.  THE  DISEASES  OF  THE  NERVOUS  SYSTEM.  <  )cUvo, 
72(1  i)a;,'es,  with  l.S4  engravings.     Cloth,  $4.50;  lejither,  $5.50. 

SCHAFER  EDWARD  A. ) .  THE  ESSENTIA  LS  OF  IIISTOL OG  Y,  DESCRIP- 
TIVE AM)  I'RACTICAL.  For  the  use  of  Students*.  Sixth  edition.  Octavo,  420 
pajjes,  with  403  illu.strations.     ('loth,  $3,  yiel. 

A    COURSE    OF  PRACTICAL    HISTOLOGY.     Second   edition.     In    one 


12tno.  volume  of  307  pages,  with  59  engravings.     Cloth,  $2.25. 
SCHLEIF  iWM.  i.      .4     POCKET    TEXT-BOO K    OF    MATERIA    MEDK'A, 

Tiii:iiAi>r.rri<.'s,  prescription  writing,  medical  latin  and 

MEDICAL   I'lIARMACY.      12ino.  3ti(l  pa-es.     Second  edition.      In  Pn^. 

SCHMAUS  (  HANS,  i  AND  EWING  (  JAMES).  PA  THOLOO  Y  AND  I' A  TIL 
OLOGICAL  ANATOMY.  Sixth  edition.  Octavo,  about  sOO  pages,  with  320  en- 
gravings in  hlack  and  colors.     /;/   Presx, 

SCHREIBER  JOSEPH).  A  MANUAL  OF  TREATMENT  BY  MASSAGE 
AND  METHODICAL  MUSCLE  EXERCISE.  Translated  by  Walter  .Me.vdel- 
SON,  M. D.,  of  New  York.     Octavo,  274  pages,  with  117  engravings, 

SENN  (NICHOLAS).  SURGICAL  BACTERIOLOGY.  Second  edition.  In  one 
octavo  volunu'  of  "JGS  ])ages,  with  13  [dates,  10  of  which  are  colored,  and  9  engravings. 
Cloth,  $2. 

SERIES  OF  CLINICAL  MANUALS.  A  Series  of  .\uthoritative  -Monographs  on 
Important  Clinical  Subjects,  in  12mo.  voliunes  of  about  ^."lO  pages,  well  illustrated.  The 
following  volumes  are  now  ready:  Caktkr  and  Frost's  Ophthalmic  Surgerv,  $2. 25 ; 
Marsh  on  Diseases  of  the  Joints,  $2;  Owen  on  Surgical  Diseases  of  Children,  $2; 
Pick  on  Fractures  and  Dislocation.s,  $2;  Yeo  on  Food,  2d  edition.  New  edition. 
Pi-fjmring. 

For  separate  notices,  see  under  various  authors'  names. 

SERIES  OF  POCKET  TEXT-BOOKS.     See  page  12. 

SERIES  OF  STUDENTS'  MANUALS.     See  next  page. 

SIMON  CHARLES  E.K  CLINICAL  DIAGNOSIS,  BY  MICROSCOPICAL 
AM)  rilh'.MK'A  L  .METHODS.  Fourth  revised  edition.  Octavo,  608  pages,  with 
139  engraving>i  and  19  full-page  plates  in  colore.     Cloth,  $3.75,  nW. 

PHYSIOLOGICAL   CHEMISTRY.     In    one    octavo   volume    of   453    pages. 

Cloth,  $3.25,  net. 

SDilON  (W.).  MANUAL  OF  CHEMISTRY  A  (iuide  to  Lw-tures  and  I.alviratory 
Work  for  Beginners  in  Chemistry.  .\  Text-book  specially  adapted  for  Student-s  of  Phar- 
macy and  .Medicine.  Seventh  edition  In  one  Hvo.  volume  of  til3  pages,  with  f4 
engravings  and  S  plates  showing  colors  of  G4  tests  and  a  spectra  plate.    Cloth.  $3.00,  net. 

SLADE  (D.  D. ).    DIPHTHERIA  ;  ITS  NA  TURE  A  ND  TREA  TMENT.    Second 

edition.      In  one  roval  12mo.  volume,  15S  pages      Cloth,  $1.2."J. 

SMITH  (J.  LEWIS).  THE  DISEASES  OF  INFANCY  AND  CHILDHOOD. 
Kighth  edition,  thoroughly  revised  and  rewritten  and  greatly  enlarged.  8vo.,  9S3  pages, 
with  273  illustrations  and  4  full-page  plates.     Cloth,  $4.50;  leather,  $5.50. 

Philadelphia,  706,  708  and  710  Sansom  St.— New  York.  Ill  Fifth  Avenue. 


14  LEA    BROTHERS    &     CO.' S    PUBLICATIONS. 

SOLLY    (S.    EDWIN).     A    HANDBOOK    OF   MEDICAL    CLIMATOLOGY 

Octavo,  46"2  pages,  with  engravings  and  11  full-page  plates.     Cloth,  $4.00. 

STILLE  (ALFRED).  CHOLERA;  ITS  ORIGIN,  HISTORY,  CAUSATION^ 
SYMPTOMS,  LESIONS,  PREVENTION  AND  TREATMENT.  In  one  12rao. 
volume  of  163  pages,  with  a  chart  showing  routes  of  previous  epidemics.     Cloth,  $1.25. 

THERAPEUTICS  AND  MATERIA  MEDIC  A.    Fourth  and  revised  edition. 


In  two  octavo  volumes,  containing  1936  pages.     Cloth,  $10. 

STILLE   (ALFRED),   MAISCH   (JOHN   M.)   AND   CASPARI   (CHAS.   JR.). 

THE  NATIONAL  DISPENSATORY:  Containing  the  Natural  History,  Chemistry^ 
Pharmacy,  Actions  and  Uses  of  Medicines,  including  those  recognized  in  the  latest  Phar- 
macopoeias of  the  United  States,  Great  Britian  and  Germany,  with  numerous  references 
to  the  French  Codex.  Fifth  edition,  revised  and  enlarged  in  accordance  with  and  enj brac- 
ing the  new  t/.  «S'.  Phannacopotia,  Seventh  Decennial  Revision.  With  Supplement  contain- 
ing the  new  edition  of  the  National  Formulary.  Imperial  octavo,  2025  pages,  with  320  en- 
gravings    Cloth,  $7.25;  leather,  $8.     With  Thumb  Index.     Cloth,  $7.75;  leather,  $8.50. 

STIMSON  (LEWIS  A.).     A  MANUAL  OF  OPERATIVE  SURGERY.     Fourth 
edition.     In  one  royal  l2mo.  volume  of  581  pages,  with  293  engravings.     Cloth,  $3.00,  net. 

A  TREATISE  ON  FRACTURES  AND  DISLOCATIONS.      Third  edition. 


In  one  handsome  octavo   volume  of  842  pages,  with  336  engi-avings  and  32  full-page 
plates.     Cloth,  $5  net ;  leather,  §6,  net ;  half  morocco,  $6.60,  net. 

STUDENTS'  QUIZ  SERIES.  A  New  Series  of  Manuals  in  question  and  answer  for 
Students  and  Practitioners,  covering  the  essentials  of  medical  science.  Thirteen  volumes,, 
pocket  size,  convenient,  authoritative,  well  illustrated,  handsomely  bound  in  limp  cloth, 
and  issued  at  a  low  price.  1.  Anatomy  (double  number);  2.  Physiology;  3.  Chemistry 
and  Physics ;  4.  Histology,  Pathology  and  Bacteriology ;  5.  Materia  Medica  and  Thera- 
peutics; 6.  Practice  of  Medicine;  7.  Surgery  (double  number);  8.  Genito- Urinary  and 
Venereal  Dise;ises;  9.  Diseases  of  the  Skin;  10.  Diseases  of  the  Eye,  Ear^  Throat  and 
Nose;  11.  Obstetrics;  12.  Gynecology;  13.  Diseases  of  Childi-en.  Price,  $1  each,  except 
Nos.  1  and  7,  Anatomy  and  Surgery,  which  being  double  numbers  are  priced  at  $1.75  each. 
Full  specimen  circular  on  application  to  publishers. 

STUDENTS'  SERIES  OF  MANUALS.  A  Seiies  of  Fifteen  Manuals  by  Eminent 
Teachers  or  Examinei-s.  The  volumes  are  pocket-size  12mos.  of  from  300-540  pages,  pro- 
fusely illustrated,  and  bound  in  red  limp  cloth.  The  following  volumes  may  now  be 
announced:  Herman's  First  Lines  in  Midwifery,  $1.25 ;  Bruck's  Materia  Medica  and 
Therapeutics  'sixth  edition),  $1.50,  net;  Klein's  Elements  of  Histology  i5th  edition), 
$2.00,  net;  Pepper's  Surgical  Pathology,  $2;  Treves'  Surreal  Applied  Anatomy, 
$2.00;  Raxfe's  Clinical  Chemistry,  $1.60;  and  Clarke  and  Lockwood's  Dissector's 
Manual,  $1.50 

For  separate  notices,  see  under  various  authors'  names. 

STURGES  (OCTAVIUS).  ^^V  INTRODUCTION  TO  THE  STUDY  OF  CLIN- 
ICAL MEDICINE.     In  one  12mo.  volume.     Cloth,  $1.25. 

SUTTON  (JOHN  BLAND).  SURGICAL  DISEASES  OF  THE  OVARIES 
AND  FALLOPIAN  TUBES.  Including  Abdominal  Pregnancy.  In  one  12mo.  vol- 
ume of  513  pages,  with  119  engravings  and  5  colored  plates.     Cloth,  $3. 

SZYMONOWICZ  (L.)  AND  MacCALLUM  (J.BRUCE).  A  TEXT-BOOK  OF 
HISTOLOGY  OF  THE  HUMAN  BODY:  including  Microtcopical  Technique. 
Octavo,  about  4',0  pagts,  with  169  original  engravings  and  55  inset  plates  in  black  and 
colors,  containing  81  figures.     In  Prehs. 

TAIT  (LAWSON'.  DISEASES  OF  WOMEN  AND  ABDOMINAL  SURGERY. 
Vol.   1.  contains  554  pages,  62  engravings,  and  3  plates.     Cloth,  $3. 

TANNER  (THOMAS  HAWKES).  ON  THE  SIGNS  AND  DISEASES  OF 
PREGNANCY.  From  tlie  second  English  edition.  In  one  octavo  volume  of  490  pages, 
with  4  colored  plates  and  16  engravings.     Cloth,  $4.25. 

Philadelphia.  706,  708  and  710  Sansom  St.— New  York,  111  Fifth  Avenue. 


LEA     BROTHERS    &     CO.'S    PUBLICATIONS.  15 

TAYLOR  (ALFRED  S.i.  MEDICAL  J bRlSI'RVDKMJE.  From  the  twelfth 
iintilisli  edition.  ri\  i>f.i  by  Cl.ARK  Bkll,  Esq.,  of  tlie  N.  Y.  Bar.  •k.-tavo,  H31  pases;, 
with  54  engravings  and   8  full-page  plates.     Cloth,  $4.50;  leather,  $5.60. 

ON  poisoys  ly  relation  to  medicine  and  medical 


JURISPRUDENCE.     Third  edition.     8vo.,  788  pages,  with  1U4  illastratioas.    (loth, 

$').o(). 

TAYLOR  ROBERT  W.  .  (.ENITO-URINARY  AND  VENEREAL  DIS- 
EASES AND  SYPII ILLS.  Second  edition.  Octavo,  720  pages,  with  1.'>.5  engravings 
and  '1~  colored  plates.     Cloth,  $5.00;  leather,  §G.OO  ;  half  morocco,  $ti.oO,  nri. 

A  PRACTICAL  TREATISE  ON  SEXUAL  DISORDERS  I^  THE  MALE 


AND  FEMALE.       Second  edition.     Octavo,  434  pages,  with  91    engravings  and  13 

plates.     Cloth,  $3.00,  net. 

A    CLINICAL    ATLAS    OF    VENEREAL    AND    SKIN    DISEASES. 


Including  I^agnosis,  Profmosis  and  Treatment.  In  eight  lar;.'f  folio  partes,  mea«iuring 
14  X  18  inches,  and  comprising  213  beautiful  figures  on  .')S  full-page  chromo-lithographic 
plates,  85  tine  engravings,  and  42o  pages  of  text.  Bound  in  one  volume,  half  Turkey 
Morocco,  $28.     Specimen  plates  by  mail. 

TAYLOR  t  SEYMOUR  1.     INDEX  OF  MEDICINE.     A  Manual  for  the  use  of  Senior 

Students  and  others,     in  one  large  r2mo.  volume  of  802  pages.     Cloth,  $375. 

THOMAS  (T.  GAILLARDt  AND  MUNDE  PAUL  F.).  A  PRAlUlaL 
TREATISE  ON  THE  DISEASES  OF  WOMEN.  Sixth  edition,  thoroughly 
revi'i'il.     Octavo  824,  pages,  with  347  engravings.     Cloth,  $5;  leather,  $6. 

THOMPSON  (W.GILMAN  I.    .4    TEXT-BOOK  OF  PRACTICAL  MEDICINE. 

Vnr  StiuUnt.'!  and  Practitioners.  ( »ctavo,  1012  pages,  with  79  illustrations.  Cloth, 
^•i.OU,   leather,  $0.00,  half  niorocco,§6.50,  net. 

THOMPSON  (SIR  HENRYK  CLINICAL  LECTURES  ON  DISEASES  OF 
THE  URINARY  ORirANS.  Second  and  revised  edition.  In  one  octavo  volume  of 
203  pages,  with  25  engravings.     Cloth,  $2.25. 

THE  PATHOLOGY  AND   TREATMENT  OF  STRICTURE  OF  THE 


URETHRA    AND    URINARY   FISTULA:.      From   the  third    English    edition. 
<  ktavo.  359  pages,  with  47  engravings  and  3  plates.     Cloth,  $3.50. 

TIRARD  (NESTOR).    MEDICAL  TREATMENT  OF  DTSEA.^FS  AND  SYMP. 
TOMS.     Hand.some  octavo  volume  of  627  pages.     Cloth,  $4.00,  rut. 

TODD      ROBERT    BENTLEY.       CLINICAL    LECTURES    ON    CERTAIN 

ACl  'TK  DISH  A  SKS.     I  ii  one  8vo.  volume  of  320  pages.    Cloth,  $2.50. 

TREVES  (  FREDERICK).     OPERA  TIVE  SURGERY.     In  two  Svo.  volumes  con- 
taining 15.50  pages,  with  422  illustrations      Cloth,  $9;  leather,  $11. 


A  SYSTEM  OF  SURGERY.     In  Contributions  by  Twenty-five  English  Sur- 

geoas.     In  two  large  octavo  volumes,  containing  2298  pages,  with  950  engravings  and 
4  full-page  plates.     Per  set,  cloth,  $16. 

SURGICAL   APPLIED   ANATOMY.     New  ediUon.      12mo.,  .577  pages,  80 


engravings.     Cloth,  $2.00,  net.     See  Studentii'   Series  of  Manuals,  page  14. 

SMITH  I  STEPHEN  ( .     OPERA  TI VE  S URGER  Y.     Second  and  thoroughly  revised 
edition.      In  one  octavo  vol.  of  892  pages,  with  1005  engravings.     Cloth,  $4;  leather,  $6. 

Philadelphia,  706.  708  and  710  Sansom  St.— Mew  York,  111  Fifth  Avenue. 


16  LEA     BROTHERS    &     CO.' S    PUBLICATIONS. 

TUTTLE  (GEO.  M.).  ^  POCKET  TEXT-BOOK  OF  DISEASES  OF 
CHILDREN.  12mo.  374  pages,  with  5  plates.  Cloth,  $1.50,  net;  flexible  red 
leather,  $2.00,  net. 

VAUGHAN  (VICTOR  C.)  AND  NOVY  (FREDERICK  G.).  CELLULAR 
TOXINS,  or  the  Chemical  Factors  in  the  Causation  of  Disease.  Xew  (4th)  edition. 
r2mo. ,  4S0  pages  with  6  engravings.     Cloth,  $3,  net. 

VISITING  LIST.  THE  MEDICAL  NEWS  VISITING  LIST  for  1902.  Four 
styles:  Weekly  (dated  for  30  patients) ;  Monthly  (undated  for  120  patients  per  month) ; 
Perpetual  (undated  for  30  patients  each  week);  and  Perpetual  (undated  for  60  patients 
each  week).  The  60-patient  book  consists  of  256  pages  of  assorted  blanks.  The  first 
three  styles  contain  32  pages  of  important  data,  thoroughly  revised,  and  160  pages_  of 
assorted' blanks.  Each  in  one  volume,  price,  $1.25.  With  thumb-letter  index  for  quick 
use,  25  cents  extra.     For  special  combination  rates  see  page  1. 

WATSON  (THOMAS).  LECTURES  ON  THE  PRINCIPLES  AND  PRAC- 
TICE OF  PHYSIC.  Fifth  edition  with  additions  by  H.  Hartshorne,  M.D.  In 
two  8vo.  volumns  of  1840  pages,  with  190  engravings.     Cloth,  $9. 

WEST  (CHARLES).  LECTURES  ON  THE  DISEASES  PECULIAR  TO 
WOMEN.     Third  edition.     Octavo  543  pages.     Cloth,  $3.75;  leather,  $4.75. 

ON  SOME  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN  CHILD- 


HOOD.    In  one  small  12mo.  volume  of  127  pages.     Cloth,  $1. 

WHARTON  (HENRY  R.).  MINOR  SURGERY  AND  BANDAGING.  Fifth 
edition.  12mo,  640  pages,  with  509  engravings,  many  of  which  are  photographic. 
Cloth.  $3.00,  net. 

WHITMAN  I  ROYAL).  ORTHOPEDIC  SURGERY.  One  octavo  volume  of 
642  pages,  with  447  illustrations,  mostly  original.     Cloth,  $5.50,  net. 

WHITLA  (WILLIAM),  DICTIONARY  OF  TREATMENT.  Octavo  of  917 
pages.     Cloth,  $4. 

WILLIAMS  (DAWSON).  MEDICAL  DISEASES  OF  INFANCY  AND 
CHILDHOOD.  Stcond  edition  specially  revised  for  America  by  F.  S.  Churchill, 
A.M.,  M.D.     Octavo,  53S  pages,  52  engravings  and  2  colored  plates.      Cloth,  $3.50,  net. 

WILSON  (ERASMUS).  A  SYSTEM  OF  HUMAN  ANATOMY.  Kevised  dition, 
octavo,   616  pages,  with  397  engravings.     Cloth,  $4;  leather,  $5. 

WINCKEL  ON  PATHOLOGY  AND  TREATMENT  OF  CHILDBED.     In  one 

octavo  volume  of  484  pages.     Cloth,  $4. 

WOHLER'S  OUTLINES  OF  ORGANIC  CHEMISTRY.  Translated  from  the 
eighth  German  edition,  by  Ira  Remsen,  M.D.     12mo.,  550  pages.     Cloth,  $3. 

WOOLSEY  (GEORGE).  APPLIED  SURGICAL  ANATOMY  REGIONALLY 
PRESENTED.  (Octavo,  511  pages,  with  125  original  illustrations  in  black  and 
colors.      In  Pres.'^. 

YEAR-BOOK  OF  TREATMENT  FOR  1898.      In  contributions    by   24  well-known 
medical  writers.     12nio.,  488  pages.     Cloth,  $1.50. 

YEO  (I.  BURNEY).  FOOD  IN  HEALTH  AND  DISEASE.  Second  edition. 
12mo.  of  592  pages  with  4  illustrations.     Cloth,  $2,50. 

YOUNG  (JAMES  K.).  ORTHOPEDIC  SURGERY.  In  one  8vo  volume  of  475 
pages,  with  286  illustrations.     Cloth,  $4;  leather,  $5. 

ZAPFFE  (FRED.  C.)  A  POCKET  TEXT-BOOK  OF  BACTERIOLOGY.  12mo., 
about  350  pages  with  many  engravings.     Preparing. 


Philadelphia.  706,  708  and  710  Sansom  St— New  York,  111  Fifth  Avenue. 


COLUMBIA  UNIVERSITY  LIBRARIES 

This  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE   BORROWED 

DATE  DUE 

DATE  BORROWED 

DATE  DUE 

czed  I40IHIOO 

/yV^ 


£S> 


(? 


/" 


-f  ^ 


■/ 


^,jrji^ 


